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PRACTICAL 

ORAL HYGIENE 
PROPHYLAXIS 

AND 

PYORRHEA ALVEOLARIS 



BY 



ROBIN ADAIR, B. S M M. D., D. D. S. 

Professor of Oral Prophylaxis and Pyorrhea Alveolaris, Southern 
Dental College, Atlanta, Ga. (1911-1913); Oral Surgeon, Grady 
Hospital (1910-1912); Oral Surgeon to Georgia Baptist Hospital; 
Member Fulton County Medical Society, Georgia State Medical 
Society, American Medical Association, Georgia State Dental 
Society, National Dental Society, and First District Dental Society 
of the State of New York. 



SECOND EDITION, ENLARGED AND REVISED 



ORAL HYGIENE PUBLISHING CO. 

Atlanta, Georgia 

1915 



LIBRA 
ENTAL SCHOOL 

w.v.u. 






Copyright 1914, 1915 

by 

ROBIN ADAIR 

a* thp Library of Congress, Washington, D. C. 



All rights reserved, including those of translation into foreign languages. 



Press of 

FOOTE & DAVIES CO. 

Atlanta, Ga. 



TO 

MY FATHER 

who for forty-five years of active practice 

has advocated the principles of Oral Hygiene 

and whose highest aspirations have been 

for his son to further the cause 

THIS WORK 

is lovingly dedicated by 

THE AUTHOR 



PREFACE TO THE FIRST EDITION. 

This book is written for those dentists who desire practical 
information on the subjects of oral hygiene, prophylaxis, 
and pyorrhea alveolaris. 

The first section is devoted to the great forward move- 
ment of oral hygiene. Here are given methods and forms 
for dental inspection of school children, and a collection of 
carefully selected lectures furnishing the proper material for 
those called upon to deliver popular talks before school chil- 
dren and women's clubs. The author has found that dia- 
gramatic pictures often prove the most convincing way to 
teach the facts of oral hygiene to a patient. This section 
contains illustrations which may be shown and explained to 
a patient while in the dental chair. 

The second section contains practical information con- 
cerning the most efficient methods to conduct prophylaxis in 
a dental practice, and names the materials to use for such 
work. The training of female assistants and the dental 
nurse question are treated in a most practical manner. 

The third section is a comprehensive description of 
pyorrhea alveolaris. Here is described in detail the methods 
of treatment now prominent before the dental profession. 
The business phase of the question, so seldom mentioned in 
discussion or literature, is presented in a frank manner. The 
medical profession is now greatly interested in the question 
of "oral sepsis." To meet this advance, the author devotes 
a chapter to their interests. 

I have frequently been asked questions on the above sub- 
jects. The articles I have written for dental journals have 
elicited numerous requests for further information, and I 
have become convinced that there is need of a book dealing 
with such matters in a thoroughly practical manner. 



I have endeavored to familiarize myself with the methods 
of other specialists in this line of work, and, from time to 
time, have visited them in their offices in order to inspect 
their work, and discuss with them the methods used. A num- 
ber of these men have been quoted, and, in some instances, 
they have prepared descriptions of certain parts of their 
work for publication in this book. 

I am fully aware that I have not always observed the 
proper literary obligations; for my accumulation of ma- 
terial collected for dental college lectures, with no idea of 
future publication, has come from a store of thoughts of 
many writers in common. 

"What he thought he might require, 
He went and took." 

All sources of information on these special subjects have 
been freely drawn on, and wherever possible, credit has 
been given for any matter used. 

Atlanta, Georgia, R. A. 

February i, 19 14. 



PREFACE TO THE SECOND EDITION. 

The manuscript for the first edition of this work was 
submitted to several leading publishers, but no satisfactory 
arrangements for its publication could be agreed upon. This 
forced the publication upon the author. A local printer 
furnished a very indifferent piece of book-work. Notwith- 
standing this unfortunate mistake, many were kind enough to 
overlook the typographical errors and the entire edition was 
subscribed for within a few months after its appearance. 

After a year this, the second edition, makes its appearance 
under more favorable circumstances. The entire subject 
matter has been carefully gone over, and brought up to date. 
Particular attention is called to the enlarged chapters dealing 
with dental inspection and clinics in schools. Several new 
lectures are added to the chapters on Popular Lectures. The 
third section of the work has been rearranged and all chap- 
ters enlarged. The most important addition is a more de- 
tailed description of the latest findings in regard to the 
bacteriology and parasitology of the Pyorrhea mouth. The 
Endameba Buccalis has received full attention. 

Another improvement is the insertion of a large number of 
new illustrations. Many of these are from the author's 
private museum. 

An index of the subject matter and an author's index have 
also been added. 

As the work goes to press, already nearly 500 advance 
orders await its appearance. The author appreciates this 
compliment to his effort and trusts a reading of its pages 
will be worth while. Many dentists who have been inter- 
ested in these subjects have kept up an active correspondence 
with the author, and for their encouragement and help he 
wishes to express his gratitude. 

Robin Adair. 

Atlanta, Ga., July 12, 191 5. 



LIST OF ILLUSTRATIONS 

Figure Page 

1. The Emergence of Temporary Teeth Above Gum ... 15 

2. The Method of Eruption of the Permanent Teeth ... 16 

3. Dentition at the Age of Nine Months 17 

4. Dentition at the Age of One Year 18 

5. Dentition at the age of One and One-Half Years .... 19 

6. Dentition at the Age of Three and One-Half Years ... 21 

7. Dentition at the Age of Six Years 22 

8. Dissected Jaws at Age of Six Years 23 

9. Dissected Jaws at Age of Eleven Years 24 

10. Dentition at Seven Years with Reference to Sixth Year 

Molars 27 

11. Irregularity Due to Loss of Six- Year Molars 27 

12. Chart Showing Want of Masticating Power in Eighty Per 

Cent, of Children at Twelve Years 28 

13. Dissected Jaws at Age of Thirteen Years 29 

14. Mal-development of Jaws Due to Loss of Six-Year Molars . 32 

15. Same Patient as Fig. 14, at Eighteen Years of Age ... 33 

16. The Ideal Dentition— Buccal View 40 

17. The Ideal Dentition — Lingual View 41 

18. Adult Dentition Showing Roots of Teeth 49 

19. Steps in Tooth Decay 64 

20. Steps in Tooth Decay 65 

21. Primitive Dentistry 80 

22. A Dental Operation on Hippopotamus 81 

23. Elephant Tooth Extraction 81 

24. Lancing an Abcess for Elephant 82 

25. Section Through Tooth and Supporting Structures ... 84 

26. Patient Before and After Treatment for Mal-formation . . 86 

27. Patient Before and After Treatment for Mal-formation of Jaw 87 

28. Same Person With and Without a Gold Crown on Front 

Tooth 88 

29. Baseball and Dentistry 89 

30. A Patient of a Free Dental Dispensary 112 

31. Training Dental Hygienists 118 

32. Dental Hygienists at Work 120 

33. Dental Hygienists at Work 120 

34. Forsyth Dental Infirmary 128 

35. Interior View of Forsyth Dental Infirmary 129 

36. Arrangement of Table for School Inspection Work ... 132 

37. Cleveland Dental Examination Form 133 

38. Back of Figure 37 134 



Figure Page 

39. Form Used For Daily Inspector 135 

40. A Record Form of Cincinnati 135 

41. An Examination Form of Cincinnati 136 

42. Card of Admission — Rochester 137 

43. Back of Figure 42 137 

44. Engagement and Record Card — Rochester 138 

45. Back of Figure 44 138 

46. A Form Used by Detroit 139 

47. Weekly Report Form — Detroit 140 

48. A Denver Form 141 

49. Denver Examination Card 142 

50. Opposite Side of Figure 49 142 

51. Tooth Brush Drill— New York 143 

52. A Revising Room — Strasburg Dispensary 144 

53. A Direction Card for Care of the Teeth 152 

54. Important Tooth Brush Movements 157 

55. The Peck Method of Brushing Teeth 159 

56. The Tongue Scraper 160 

57. An Infected Tooth Brush 163 

58. Dental Floss Card— Spalding 167 

59. Direction for Using Dental Floss 167 

60. Flushing Apparatus — Kells . . . _ 168 

61. Protection for Dental Handpiece 179 

62. Age Curve in Prophylaxis 197 

63. Hand Polishers for Prophylaxis 216 

64. Shape of Cotton Wood Stick for Prophylaxis 217 

65. Fissure in Bicuspid Tooth 221 

QQ. Prophylaxis Notification Card— Kells 224 

67. Prophylaxis Notification Card — Fones 225 

68. Prophylaxis Engagement Book 226 

69. Prophylaxis Engagement Card — Adair 227 

70. Prophylaxis Notice Card — Adair 228 

71. Prophylaxis Notification Card — McCall 230 

72. Record Card— McCall 233 

73. Enlarged Section of McCall Record Card 234 

74. Reception Room Card 256 

75. Dental Nurse at Work 263 

76. Announcement of Employment of Dental Nurse .... 264 

77. A Card to Advance Fees 265 

78. X-Ray Pictures of Pyorrhea Cases Complicated With Bridge- 

work 288 

79. Kind of Bridgework that Causes Pyorrhea 289 

80. Deposits of Salivary Calculus 302 

81. Serumal Calculus 303 

82. Pyorrhea Mouth Showing Recession of Gum 307 

83. Pyorrhea Mouth Showing Pus Exudation 309 



Figure Page 

84. Tumefaction of Gum Tissue 310 

85. Skull Showing Effect of Pyorrhea 313 

86. X-Ray Pictures of Pyorrhea, Case Before and After Treat- 

ment 314 

87. Eroded Teeth in Pyorrhea 318 

88. Alveolar Abscesses 320 

89. Separation of Teeth in Pyorrhea 323 

90. A Typical Case of Pyorrhea 326 

91. X-Ray Pictures of Pyorrhea Cases 329 

92. Kirk Dental Scalers 343 

93. Alport-Adair Instruments 344 

94. Bates' Scalers 345 

95. Younger Pyorrhea Instruments 347 

96. The Good, Revision Instruments 348 

97. Smith Prophylaxis Instruments 349 

98. Tanner Polishing Files 350 

99. Tompkins' Pyorrhea Files 351 

100. Solution Holder for Office 353 

101. Hartzell Type of Instrument 357 

102. Fletcher Set of Bone Curettes and Alveolar Burs ... 363 

103. LeRoy Type of Instrument 366 

104. Celluloid Syringe with Platinum Point 375 

105. Radiographs of Pyorrhea Case — Merritt 378 

106. 107, 108. Examination and Record Card for Pyorrhea 

Cases— West 384, 386 

109. A Simple Pyorrhea Chart 390 

110. Hypodermic Syringe Point for Pyorrhea 394 

111. Diagrammatic Illustration of Operative Steps in Pyorrhea 

Work 396 

112. The Clark Air Syringe 397 

113. A Pyorrhea Case 398 

114. Carious Alveolar Process in Pyorrhea 399 

115. A Pyorrhea Case 401 

116. Treatment Applicators 406 

117. Hypercementosis of Pyorrhea Teeth 417 

118. Amputated Roots in Pyorrhea Cases 418 

119. Proper Bridgework for Pyorrhea Cases 422 

120. Upper Jaw Bridgework for Pyorrhea Case 423 

121. Temporary Wire Splint 425 

122. A Charge for Time Card 437 

123. Notice for the Estimate Sheet 439 

124. A Form of Professional Note 441 



CONTENTS 



PART I. 
Practical Oral Hygiene. 



chapter I. 

Page 
Oral Hygiene Movement. — Progress Made and Prediction for the 
Future. — The Industrial Dental Dispensary. — Oral Hygiene in 
the Army and Navy. — Oral Hygiene in Literary Colleges.. 3 to 13 

CHAPTER II. 

Oral Hygiene from Infancy. — Some Fundamental Observations. — 
Sixth Year Molars. — Mastication of Food. — The Neglected 
Mouth 14 to 34 

CHAPTER III. 

Popular Lectures on Dental Subjects. — "Teeth and Their Care," 
Lecture Issued by Michigan Dental Society. — Outlined Lec- 
tures by Dr. Stevenson: (1) For Mothers' Clubs, (2) To Chil- 
dren, (3) For Nurses and Physicians, (4) To Kindergarden. — 
Lecture by Dr. Albray 35 to 61 

CHAPTER IV. 

Popular Lectures — Continued. — An Illustrated Lecture by Dr. Zar- 
baugh. — Lecture for School Children from Fourth to Eighth 
Grade, by Dr. Corley 62 to 78 

CHAPTER V. 

Popular Lectures — Continued. An illustrated Lecture by Dr. 

Hyatt.— Lecture for School Children by Dr. Hunt 79 to 100 

CHAPTER VI. 

Dental Examination and Clinic for Public Schools. — History. — 
School Inspection. — How to Start School Inspection. — Reasons 
for Free Dental Clinic and School Inspection. — "Importance 
of Dental Inspection," by Dr. Zarbaugh 101 to 116 



CHAPTER VII. 

Page. 
Dental Inspection and Clinics for Public Schools — Continued. — The 
Dental Hygienist in Bridgeport. — The Morristown Clinic. — The 
Detroit Idea. — Forsyth Dental Infirmary. — Instructions for 
Making School Examination. — Forms Used for Inspection and 
Clinic Work 117 to 144 

CHAPTER VIII. 
Tuberculosis and the Oral Hygiene Movement 145 to 149 

CHAPTER IX. 

Brushing the Teeth. — Shape of the Brush. — Teaching the Technique 
of Brushing the Teeth. — The Direction Card. — The Care of the 
Tooth Brush.— The Proper Use of the Tooth Pick.— The Use of 
Dental Floss Silk.— The Bad Breath Signal.— Lime Water as 
a Mouth Wash 150 to 172 

CHAPTER X. 

Cleaning the Teeth.— Skill Required for the Work.— The Best Time 
to Clean the Patient's Teeth. — The Use of a Disclosing Solu- 
tion. — Instruments Used for Cleaning the Teeth. — Abrasive 
Mixtures Used in Cleaning the Teeth 173 to 181 



PART II. 

Practical Oral Prophylaxis 

chapter XI. 

Oral Prophylaxis. — Definition and Views of Smith, Spalding, 

Fletcher, Fones, Thorpe, Taylor, Rhein and Harper 185 to 193 

CHAPTER XII. 

Why is Prophylaxis Necessary? — When to Begin Prophylaxis. — 

Frequency of Treatment.— Object of Prophylaxis 194 to 203 

CHAPTER XIII. 

The Prophylaxis Class. — Preliminary Work Before Entering Pa- 
tient on Prophylaxis. — Prophylactic Technique. — Views of 
Kelley, Goble and Johnson 204 to 213 



CHAPTER XIV. 

Page. 
Instruments and Polishing Materials Useful in Prophylaxis. .214 to 219 



CHAPTER XV. 

Prophylactic Treatment of Fissures and Grooves. — Soft Spots and 

Sensitive Area Treatment 220 to 223 

CHAPTER XVI. 

Methods of Notification as Used by Kells, Fones and Adair. .224 to 228 

CHAPTER XVII. 

Methods of Notification and Records of Cases. — "Notification of 
Patients — Records of Cases," by Dr. John Oppie McCall. — 
Notification Systems of Dr. Henry A. Kelley, Dr. Gillette 
Hayden and Dr. Grace R. Spalding 229 to 239 

CHAPTER XVIII. 
Results of Prophylactic Treatment 240 to 242 

CHAPTER XIX. 

Some Important Observations on the Teeth and Saliva. — Tooth 
Enamel 243 to 249 

CHAPTER XX. 

Training of Female Assistant. — Time for Installing Assistant. — 
Where to Secure Best Help. — Office Training for the Position 
of Dental Nurse 250 to 258 

CHAPTER XXI. 

The Dental Nurse. — Views of Fones, Merritt, Hyatt, Hart, Eber- 
sole, Nodine, Kirk and Skinner. — An Act to Regulate the Prac- 
tice of Oral Prophylaxis by a Registered Dental Assistant. — 
The Massachusetts Dental Society Bill 259 to 270 

CHAPTER XXII. 

Teaching of Oral Hygiene, Prophylaxis and Pyorrhea in Dental 
Colleges. — Practical Methods Employed by the Author. — The 
Results Obtained.— The Need of Such Instruction 271 to 27G 



PART III. 

A Practical Description of Pyorrhea Alveolaris 
and Its Treatment. 

chapter xxiii. 

Page. 
Pyorrhea Alveolaris. — Synonyms. — Nomenclature. — Definitions. — 
Causes. — What is Tartar and Its Formation? — Kinds of De- 
posits Found on the Teeth. — Black's Theory of Tartar Forma- 
tion 279 to 305 

CHAPTER XXIV. 

Pathology of Pyorrhea Alveolaris. — Recession and Congestion of 
the Gums. — The Peridental Membrane. — The Alveolar Process. 
— Tooth Root Absorption. — Formation of Pus Pockets. — Alveo- 
lar Abscess in Pyorrhea 306 to 321 

CHAPTER XXV. 

Symptoms, Duration and Diagnosis of Pyorrhea. — "The Value of 
the Radiograph in Pyorrhea," by Nodine 322 to 332 

CHAPTER XXVI. 

Prognosis. — Blood Pressure. — Artificial Teeth in Regard to Pyor- 
rhea 333 to 341 

CHAPTER XXVII. 
Instruments for Use in Prophylaxis and Pyorrhea Work 342 to 351 

CHAPTER XXVIII. 

Instrumentation. — Sterilization of Instruments and Preparation of 
the Mouth for Surgical Work. — Cleansing the Field of Opera- 
tion. — "A Technical Description of the Surgery of the Root 
Surface," by Dr. Thomas B. Hartzell. — Treatment of Pyorrhea 
Alveolaris, by Dr. John Deans Patterson. — The Sarrazin Treat- 
ment. — Fletcher's Method of Removing Diseased Alveolus. — 
Dr. L. C. LeRoy's Method 325 to 369 

CHAPTEK XXIX. 

Drugs Commonly Used. — Treatment in General for Pyorrhea. — 
Medical Application Used by Younger, Meisberger and 
Head 370 to 376 



CHAPTER XXX. 

Page. 
Treatment — Continued. — Treatment of Merritt, Dunlop, Lundy, 

West and Reid 377 to 388 



CHAPTER XXXI. 
Author's Method and System of Treating Pyorrhea 389 to 401 

CHAPTER XXXII. 

The Author's Method and System of Treating Pyorrhea — Continued. 
— Applying Dressings in Pyorrhea. — Method of Making Nos. 1 
and 2 Pyorrhea Dressing. — Directions for Post-Operative 
Dressing. — Auto-Intoxication in Pyorrhea. — Silver Nitrate in 
Pyorrhea Treatment 402 to 412 

CHAPTER XXXIII. 

Special Operations in Pyorrhea. — Implantation. — Bifurcation Treat- 
ment. — Removal of Pulps. — Amputation of Roots. — Treatment 
of Pyorrheal Abscess. — Bridge Work in Pyorrhea. — Splints 

413 to 428 

CHAPTER XXXIV. 
Vaccines and Emetine in the Treatment of Pyorrhea 429 to 435 

CHAPTER XXXV. 
Business Side of Pyorrhea Alveolaris 436 to 443 

CHAPTER XXXVI. 

The Medical and Surgical Aspect of Oral Hygiene and Pyorrhea. — 
Views of Prominent Medical Men. — Suggestions to Physicians 
as to Care of the Mouth in Sickness. — Oral Preparation for 
Surgical Work 444 to 455 



PART I. 
PRACTICAL ORAL HYGIENE. 



CHAPTER I. 
ORAL HYGIENE MOVEMENT. 

PROGRESS MADE AND PREDICTION FOR THE FUTURE. THE 

INDUSTRIAL DENTAL DISPENSARY. ORAL HYGIENE IN 

THE ARMY AND NAVY. ORAL HYGIENE IN LIT- 
ERARY COLLEGES. 

PROGRESS MADE AND PREDICTION FOR THE FUTURE. 

Only in recent years have some of the more progressive 
dentists begun to realize their duty to the public in the mat- 
ter of educating them to the importance of prophylactic 
and oral hygienic measures in the care of their teeth, and of 
teaching them the great results which can thus be secured in 
the way of increased health, happiness and freedom from 
disease. This propaganda has been termed the Oral Hy- 
giene Movement. 

It must be admitted that the slowness of the dentists in 
realizing their duty along this line has been discouraging 
to those who have had the interest of the movement at 
heart, but we all know that the dental profession is a busy 
and hard working profession, having strenuous require- 
ments on its time and resources. Still the time can not be 
far distant when the dentists of America will realize their 
great opportunity as well as their duty along the line of 
educating the people. It will mean the placing of the propa- 
ganda on a higher plane of usefulness and the accomplish- 
ment of results in every way equal to the best work done in 
recent years by the medical profession in the line of pre- 
ventive medicine. 

It can already be noticed that the dentists of this coun- 
try who are interesting themselves in this movement are 
taking the places at the head of the profession, and are 



4 Practical Oral Hygiene. 

reaping just rewards for their work in furthering the pub- 
lic welfare. 

It has been stated that only twelve per cent, of any 
community pays any attention to the teeth, but, since we 
know how inefficient most of this care is, we realize that 
a very much smaller percentage practices oral hygiene in 
a really efficient manner. 

It is somewhat of a reflection on the dental profession 
that a layman, Mr. Horace Fletcher, did more in a few 
years to acquaint the people with oral hygiene facts than 
did the whole dental profession in its former career. 

The public is beginning to be aroused on the subject of 
oral hygiene and they read eagerly the magazine and daily 
newspaper articles on the subject. The whole trouble to- 
day is that just such trustworthy (?) facts are given them 
as are to be found in the columns, "Advice to the Love- 
lorn," and "How to Remove Freckles." 

Not all dentists are in possession of facts relating to the 
general health and welfare, which if properly presented to 
the laity, would soon make the advice of the dentists as 
much sought after as is that of the medical man. The truth 
is that up to the present time, the laity and the medical pro- 
fession have been ignorant on this subject, and for the sim- 
ple reason that the dentists themselves have not done their 
duty in the way of educational propaganda. 

One reason for the lack of knowledge on the part of the 
public is shown by the following quotation taken from a 
common school physiology: 

"The teeth are bony keys set in the jaw-bones. Those 
in the front part of the jaw are sharp, so as to bite lumps 
of food. Those in the back part of the mouth are flat, 
so as to grind food to pieces. Between the ages of 6 and 
13 the child loses its first teeth and gets a whole new set, 
and 8 additional ones. Biting hard things, such as nuts and 
wood, often breaks the enamel and causes the teeth to de- 
cay. When the decay reaches the nerve, the tooth aches 
and becomes very tender." 



The Industrial Dental Dispensary. 5 

These false impressions, gained at an early age, are very 
hard to overcome when the children grow older. We should 
bend our energies to correct this state of affairs by estab- 
lishing in our schools a brief but thoroughly scientific course 
on these subjects. 

Not only does the proper dental attention give the owner 
the means whereby he can more comfortably masticate his 
food, but also serves as a preventive against those agents 
which make against his general physical welfare. The lack 
of this attention not only causes a filthy condition, which 
furnishes the bed where germs can readily grow, but also 
lowers the patient's resistance, and this results in physical 
deterioration. 

A few years ago this fact was not generally recognized, 
but to-day the army and navy, the big factories, and even 
the baseball clubs often employ a good dentist, for the pur- 
pose of protecting their employees. 

THE INDUSTRIAL DENTAL DISPENSARY. 

The match factories were the first to recognize the bene- 
fits of protecting their employees against mouth infections. 
Previous to dental inspection and care, phosphor-necrosis 
was a dreaded and common affliction among those thus em- 
ployed. Since the employment of a regular dentist, this 
condition has been reduced to a rarity. 

Morris and Co., one of the big stock yard firms of Chi- 
cago, have just installed a fully equipped dental office for 
the purpose of giving their thousands of employees free 
dental attention. This firm was convinced that the health 
of its workers would be better, and that a great saving of 
time would result from having a dentist close at hand. This 
special inducement to these people saves many teeth which 
would otherwise be lost. 

This is in line with the efforts of many of the larger cor- 
porations to guard against any thing which would incapaci- 
tate the employees from giving good service. Undoubtedly, 



6 Practical Oral Hygiene. 

bad teeth are the greatest cause for loss of time, and these 
free clinics will, in time, be a regular equipment. 

The Metropolitan Life Insurance Company, of New 
York, has recently established a dental clinic in its home 
office. Dr. T. P. Hyatt, the dental director for this clinic, 
writes: "I believe I am safe in saying that this is the first 
insurance company to have a dental director. Prophylactic 
treatment and examination will be given to those employees 
who wish to take advantage of this offer. Some 2600 have 
already expressed their intention of availing themselves of 
this opportunity. To meet this demand five chairs are being 
installed with five operators and four assistants. Charts 
have been designed for recording the condition found and 
provision made for recording, when necessary, the previous 
health record which can be copied from the Medical Rec- 
ord. There is also space provided for the results of radio- 
graphic, bacteriological and saliva tests. 

"Those cases that are found to need operative dental 
work will be provided with a slip showing the teeth requir- 
ing attention, and be referred to their own dentist for this 
work with the request to report back to the dental clinic 
as soon as the work is completed. In this way it is hoped 
to keep the employee in good dental condition as prophy- 
lactic treatment and examination will be made twice a year. 
It is expected that valuable data will be secured showing 
an improvement in the health and efficiency of those who 
receive this dental attention." 

Large industrial concerns like the Armstrong Cork Com- 
pany, the Heinz Preserving Company, and the Larkin Soap 
Factory have established dental dispensaries in connection 
with their plants. The large department stores of Wanna- 
maker, and Lord & Taylor, have installed a dental clinic. 
Dr. C. G. Anderson, the director of the dental clinic of 
Lord & Taylor, of New York, writes: "No charge is made 
for oral prophylaxis or instruction as to the proper method 
of tooth cleaning. . . . All employees undergo phys- 



The Industrial Dental Dispensary. 7 

ical examination previous to their acceptance by this firm, 
and the time is not far distant when oral examination will 
be included and none accepted unless 'passed' by the dentist. 
This is practically in effect now. If the examining doctor 
discovers dental defects, the applicant is instructed to have 
same remedied or is not accepted." 

The prediction can be made that the day is not far dis- 
tant when our department stores and other business houses 
where the clerks come in contact with customers, will pro- 
vide either by pamphlet and lecture, or by furnishing free 
prophylaxis, the necessary means for insuring a healthy con- 
dition of their employees' mouths, and it will certainly more 
than repay them for the time and money expended. We 
know that when a clerk with unkept teeth, shining crowns, 
and bad breath waits on us, it makes a difference. It also 
makes for a sale, if the clerk has a pretty, well-kept mouth. 
Here is a fertile field for the oral hygiene worker; this class 
of people can not pay for expert services. It costs too much 
and the loss of time is also an item. They are often the 
victims of dental parlors where their teeth are fitted with 
golden trappings which shine out as the headlights on an 
automobile. 

Many of the larger southern cotton mills either employ 
a dentist for their employees, or make it to his interest to 
locate in the vicinity by giving him free rent or by other 
means. One mill in the Piedmont district, which owns the 
township, selected a well-equipped young dentist and gave 
him free rent, assured him the influence of the officials in his 
oral hygienic endeavors, and guaranteed him freedom from 
competition by the more or less conscienceless dentists who 
often infest such places. He is free to give these mill oper- 
atives much valuable advice and treatment, and in turn, they 
furnish their employers better work. 

One not familiar with the ignorance and prejudices ex- 
isting among these cotton mill operatives, can not imagine 
the difficulties to be met with in trying to make better their 



8 Practical Oral Hygiene. 

conditions. Not long ago I was in the township mentioned 
and questioned some of these people about their teeth. I 
was congratulating them on having such a good dentist as 

Dr. . One of them said, "Dr. may be a 

very good fellow, but I am not going to let him work for 
me or my family any more, for," said he, "I had the dickens 
of a toothache and went up to him to get it pulled and he 
commenced some rot about cleaning teeth and saving my 
tooth. I didn't have any time for such stuff, and went to 

Greenville and got Doc. to pull it. Dr. 

used to pull teeth, but he has got to talking so much about 
clean mouths that he is losing some of his trade." While 
the contemplation of such a clientele is not pleasant, it em- 
phasizes more than ever the need of education on these sub- 
jects. 

If we have any patients who control mills, it is our duty 
to show them the benefits of such service, and suggest some 
good young dentist for the position. To "some good young 
dentist" the suggestion is offered that he see some mill official 
with whom he is acquainted, and show him the immense ad- 
vantages to be derived from having the right sort of dentist 
connected with the mill. The experience is well worth while, 
the good done incalculable, and the financial returns are gen- 
erally satisfactory if the co-operation of the officials is se- 
cured. 

At the present time where wages are high and hours 
short, officials who control large numbers of operatives are 
rapidly awakening to the advantages of measures which will 
enable them to secure more efficient services from their em- 
ployees. As regards medical advice they are always ready 
to have lectures on sanitation, and the suggestions of the 
resident physician are most readily carried out. 

ORAL HYGIENE IN THE ARMY AND NAVY. 

If we could only realize that the condition of faulty 
mouths keeps our young men out from even such employ- 



Oral Hygiene in the Army and Navy. 9 

ment as the Army and Navy, and that so few are able to 
pass the simple requirements, we might wake up on this 
subject. Even more so, when considered that, had the 
oral hygiene movement started back when these applicants 
were children, they would not be hampered in this way. 
In our Philippine Army thirty-five per cent, of the catarrhal 
dysentery is said to be traceable to septic mouth conditions. 

Thousands of applicants for our Army and Navy are re- 
jected because of faulty teeth. Not only is this true in our 
Army, but in England also, it has been said that five hun- 
dred were rejected in one year because of improper oral 
conditions. Further than this, a report states that twenty- 
four per cent, of the English Army recruits have useless 
teeth. At Annapolis an average of only two per cent, of 
the men who apply for entrance, pass without first having 
some dental work done. 

Germany has recognized that the great efficiency in her 
army is increased by attention to oral hygiene. The present 
requirement is that each soldier shall brush his teeth at least 
once a day, and the first sergeant in each company must see 
that this order is obeyed. Many other countries have taken 
steps along this line in regard to the armies. While Amer- 
ica will probably never exercise this parental care, still we 
are bordering on this, for in the Philippine Army the sol- 
diers are required to have monthly examinations of their 
mouths by the Post Surgeons. 

The American Army and Navy employ the best of den- 
tists, who secure their positions, not through any politics or 
favoritism, but by standing the hardest kind of examination. 
These men not only do repair work for the soldiers, but 
they, working with the medical authorities, see that their 
mouths are kept clean. It is a remarkable story that the 
Surgeon General was willing to raise the dental requirements 
for admission into the Army and Navy, yet, when the raise 
was attempted, it was found that the number of recruits was 
so reduced that the old standard had to be accepted. 



io Practical Oral Hygiene. 

Undoubtedly, more and better oral hygiene will be taught 
and required each year in our Army, and the officials in 
charge will find that greater efficiency, better health, and a 
better fighting force can be maintained by having the men 
keep their mouths in a clean condition. 

ORAL HYGIENE IN LITERARY COLLEGES. 

One of the largest and best military schools for boys is 
located about ten miles from Atlanta. The attendance is 
gathered from all over the United States, and many foreign 
countries are represented. I have had the pleasure of hav- 
ing many of these boys for patients. Almost without ex- 
ception, they have presented mouths needing much attention, 
especially for oral sepsis. The time lost by these boys going 
to and from the dentist, and the loss of study-time due to 
pain is enormous. 

The same condition prevails at our educational institutions 
situated in all our cities. While the dental inspection of 
our public schools is productive of much good, it is undenia- 
bly true that we are neglecting just as great a field in the 
colleges. These institutions are filled with young ladies and 
gentlemen who are to be the future parents and who can 
be made our earliest and best missionaries. At this age, 
fourteen to twenty-two, they are very receptive to sugges- 
tions on oral hygiene. Their ignorance of their mouth con- 
ditions and the great loss of time for the necessary dental 
attention causes many to delay until too late. Even those 
who endeavor to have their teeth looked after are some- 
times recommended to the poor operators. I have known 
of several cases where inferior dentists have secured some 
of the teachers in a school for patients and have done their 
work free of charge with the understanding that the teach- 
ers solicit work for them among the students. In one of 
these instances the college officials were unable to overcome 
a teacher's persuasive powers with the students and the lat- 
ter were led to patronize a man who was about on a par 



Oral Hygiene in Literary Colleges. ii 

with those employed to work in dental parlors. This hap- 
pened in a large institution. How much better it would 
have been for the president to have had on his staff a repu- 
table dentist to reside in or near the college, or to have had 
a city dentist come to the college on regular days and do the 
necessary dental work in a well-equipped dental office in the 
college building. Think of the better service and the sav- 
ing of time and trouble to the teachers and students. Every 
institution can afford a well-equipped hospital, whereas the 
cost of a dental office need not be nearly so much as that of 
the hospital. 

Some years ago, I accepted an invitation to deliver a lec- 
ture on the subject of "Teeth," at one of our larger female 
colleges. One of the local dentists got interested, worked 
up some enthusiasm, arranged the date, secured a lantern, 
and introduced me. My whole theme was turned to what 
benefits they could secure by a course on "Oral Hygiene." 
I made this lecture as dignified and impressive as study and 
slides could do. The president and the dentists followed up 
the suggestions, and now for several years, this institution 
has been giving the students a regular and systematic course 
in oral hygiene. There is a possibility that spasmodic lec- 
tures may do some good but if the work is carried out in 
the regular curriculum, as in the college just mentioned, 
great good can be accomplished. 

Every educational institution needs, and should have, 
either a dental clinic or a dental department. A few years 
ago the practical application of this statement would have 
been questioned, but to-day the proposition does not admit 
of argument. Many institutions have operated such de- 
partments long enough to prove beyond a doubt both the 
necessity and the practical value of such service. One in- 
stitution has gone into this matter so thoroughly, and with 
such success, that I include a long quotation with reference to 
their work. This quotation is taken from the United States 
Bureau of Education Bulletin, 19 14, No. 40, whole number 



12 Practical Oral Hygiene. 

614, on the subject of "Care of the Health of Boys in Girard 
College, Philadelphia, Pa.": 

"Realizing the importance of the care of the teeth as a 
factor in the conservation of normal development and the 
health of the boys, and with the knowledge that a large 
percentage of disease and lack of mental and physical de- 
velopment are due to deleterious effects resulting from neg- 
lect and improper treatment of diseased conditions and mal- 
occlusion of the teeth, the board of directors of Girard Col- 
lege reorganized the department of dental surgery, which 
was formally opened on September 11, 191 1. It is com- 
posed of three operating rooms, a waiting room, and a den- 
tal laboratory. 

"The whole equipment in this department was selected 
and installed with the greatest care. The fitting out of what 
is one of the most elaborate dental departments to be found 
in any institution or school of this kind in the world has for 
its sole object and aim the care of the boys in Girard College 
and the practice of dentistry for them as an exact science. 
An elaborate equipment of this character has been considered 
unnecessary in most institution and school work; in fact, the 
care of children's teeth, particularly the temporary teeth, has 
been, as a rule, neglected by both parent and dentist. 

kk With the enormous task of caring for and establishing 
a healthy condition in the mouths of approximately 1,500 
boys, the necessity for having every facility at hand for 
rapid, thorough, and careful work is quite obvious. The 
white marble partitions, white enameled steel cabinets with 
porcelain tops, white enameled chairs, engines, and switch- 
boards were selected to create an impression of cleanliness 
and refinement which we desire the boys of Girard College 
to have of their dental department. On leaving college the 
boys will then seek to have their teeth cared for in an office 
where a carefully selected equipment is available and where 
a high standard is maintained. These are usually found 
in the offices of the most progressive men, who realize that 



Oral Hygiene in Literary Colleges. 13 

in their adoption they are enabled to advance their work 
to its highest degree of perfection. 

"Perhaps the most evident good result has come from 
the new dental department. The present plan of caring for 
the teeth was introduced in September, 191 1, and the im- 
proved condition in the health of the boys and in their per- 
sonal appearance has been most marked since that date. 

"It is not deemed sufficient to treat the boys in Girard 
College for present diseased conditions only, but to study 
the oral cavity as a whole. By prophylactic methods a 
healthy and aseptic condition is established as nearly as pos- 
sible." 



CHAPTER II. 
ORAL HYGIENE FROM INFANCY. 

SOME FUNDAMENTAL OBSERVATIONS. — SIXTH YEAR MOLARS. 
MASTICATION OF FOOD. THE NEGLECTED MOUTH. 

SOME FUNDAMENTAL OBSERVATIONS. 

Oral hygiene for the infant should start at its birth, and 
be maintained by the trained nurse until the child is turned 
over to the regular nurse and the mother, who in turn, 
should be taught to carry out our instructions for keeping 
the mouth in a cleanly condition. Milk, whether from the 
mother's breast or the cow, readily ferments in an exposed 
warm place, such as the child's mouth. Nearly all cases of 
stomatitis in young children are due to an unclean condition 
of the mouth. The particles of milk left in the mouth fer- 
ment and give a most fertile field for the growth of micro- 
organisms, which readily attack the soft and tender mucous 
membrane. When infections caused by these, such as follic- 
ular stomatitis appear, the child can not nurse properly. 

If properly done, nothing but good can result from wash- 
ing a baby's mouth. The manner of doing this is one of 
the simplest things, and yet, in my college work, after lec- 
turing on the subject, I have found that few students remem- 
bered it at the time of their final examinations. The first 
requisite is clean hands. Around the index finger is wrap- 
ped a small amount of aseptic cotton; the cotton is then 
saturated with a solution of boric acid. The child is held 
in the arms with the head slightly back, and, as most children 
when held in this position open their mouths, the finger can 
be inserted easily. The part of the mouth which needs the 
most attention is not the top of the gum surface, as many 



Some Fundamental Observations. 



i5 



seem to think, but under the tongue, and at the lower sur- 
faces on the buccal sides of the cheek in places where milk 
remains. Do not use gauze on the finger as it is entirely 
too rough. Rubbing is not necessary, but the simple cleans- 
ing by removing the milk debris is the proper idea. The 
best time for this is after the morning bath and the procedure 
may be repeated at night with good results. 



7 TO 10 

MONTHS 



10. TO 12. 

MONTHS. 




A '. CENTRAL 

B. LATERAL 
C. CANINE 



MOLAR 
r"MOL/\R 



Fig. 1. To Illustrate Eruption of the Temporary Teeth, i. e., Their 
Emergence Above the Gum. (Harrison.) 



When the child is about nine months old, the same method 
is used, and in addition, care should be exercised in wiping 
around whatever teeth have erupted at this time. About 
the tenth month it is well to secure a soft camel's hair brush, 
one in which the hairs do not shed, and very carefully brush 



i6 



Practical Oral Hygiene. 



the teeth from the gums with a rotary motion, using a brush 
which has been dipped in boric acid solution. At this age 
the child will object to the cleansing and it should be done 
more in a spirit of play by the mother herself. Now, too, 
the child will enjoy the friction of the brush upon the gums. 
The gums may now be brushed and a small amount of 
massage given. This will stimulate the growth of the teeth 
and prove to be a great aid towards their eruption. If the 
spirit of play in this brushing is carried out, the child early 
learns to brush its own teeth, and if kept up, the tooth brush 
habit will be so instilled into the child's mind that much pain 
and many decayed teeth will be prevented in the future man 
or woman. 



; 








V 


■ e r*l>L}£J 








A ^ If 




lUMIMnn ml 



Fig. 2. A Normal Dentition at Seven Years. 



Premolars 



}' 



Molars 



The Temporary Teeth : 

A. Central ) T . 

B. Lateral } Inc,sols 

C. Canine 

D. 1st 
E". 2nd 

The Permanent Teeth: 

1. Central ) T . 

2. Lateral } Incisors 
A dissection showing the method of the eruption of the second or 

permanent set of teeth and the way they replace the deciduous ones. 
Note particularly that the tooth 6 behind the black line is a permanent 
one, and that it erupts independently at 6 years, and does not replace 
a temporary one. (Pedley.) 



3. Canine 

4. 1st 

5. 2nd 

6. 1st Permanent Molar, com- 

monly called the 6- Year 
Molar 

7. 2nd Molar, or the 12-Year 

Molar 



Some Fundamental Observations. 17 

In dealing with the infant's jaw, we must explain to the 
mother that concealed in the little jaw there are twenty teeth 
and, in addition to this, the germs of the permanent molars; 
or, to go further, in the various phases of development are 
fifty-two teeth; and that the stress caused by this tremendous 
amount of nature building is very great. The comfort and 
health of the child depends on the temporary teeth, for their 
purpose is to serve until the permanent teeth take their 
places. The body of the child during the time served by the 
temporary teeth almost doubles in weight. If these teeth 
are allowed to decay off even with the gums, or if abscesses 
are allowed to form, we know that the child's body will not 




Fig. 3. Dissected Superior and Inferior Maxillary Bones, Showing 

Development and Eruption of Temporary Teeth at 

the Age of 9 Months. 

(Figs. 3 to 9 and 13 by permission Haskell Post-Graduate Dental 

College.) 



1 8 Practical Oral Hygiene. 

develop as it should during this time. These are elementary 
facts, but unless we recall them to our minds, we are apt 
to forget to remind the parent, teacher, or child of them. 




Fig. 4. Dissected Superior and Inferior Maxillary Bones, Showing 

Development and Eruption of Temporary Teeth at the 

Age of 1 Year. 

Thousands of infants die each year because indigestible 
foods and unnatural nourishment are given them, this caus- 
ing so much digestive disturbance that the teeth are unable 
to develop for proper eruption. We often see these dis- 
orders during dentation so serious as to cause convulsions. 
The author used to claim that, as dentation was a physio- 
logical process, any unpleasant effects during this term of 
stress were the parents' fault. However, after having per- 
sonal experience with children of his own, where every pre- 
caution possible was taken, and where the proper food was 



Some Fundamental Observations. 19 

given (as shown by the strong, healthy bodies and good 
bone structure) — still, in spite of this care, there was severe 
sickness and convulsions. Inquiry into other cases, where 
my advice had been asked, revealed the same state of affairs. 
This proves to me that, while these measures are advisable 
and necessary, a certain amount of trouble is even then apt 
to occur. We do know, also, that where the child is not 
fed properly, soft bones and unhealthy skin are the result 
and that where one child dies, hundreds of others must be 
punished in the future by weak bodies as a consequence of 
such negligence on the part of the parents. 




Fig. 5. Dissected Superior and Inferior Maxillary Bones, Showing 

Development and Eruption of Temporary Teeth at the 

Age OFiy 2 Years. 

The change from the temporary to the permanent teeth 
has been likened to a railroad station. The traffic must 



20 Practical Oral Hygiene. 

go on, the passengers and mails must be handled; yet 
the old depot is torn away and the new one established with- 
out disturbing any of the relations of the important traffic. 
Should anything happen to these trains, serious complica- 
tions are sure to follow. So it is with the child: the tem- 
porary teeth are receiving their freight, the food, and it is 
very necessary that they should all be at the post of duty. 
One by one, nature takes them away and replaces them by 
proper structures. This can and should be done with no 
more inconvenience to the child than is suffered by traffic 
when a depot is replaced by a large passenger station. If 
anything should happen to the child's teeth so that they are 
not as strong as they should be and daily use is prohibited, 
we shall always find a defective individual. Thus, it be- 
hooves the dentist to call the attention of the mothers to the 
importance of proper feeding. 

Undoubtedly one of the most serious calamities which can 
occur to a child is the pushing out of the front portion of 
the jaws. This is often caused by the rubber teats or paci- 
fiers, and by thumb-sucking. No child's jaw remains nor- 
mal if such things are allowed. This is so serious as often 
to cause enlarged tonsils and adenoids in addition to the 
pushing out of the jaw. Many prominent physicians recog- 
nize the danger from such sources and recommend that the 
rubber teats be laid aside and that a large-size finger cot be 
used on the spout of the ordinary feeding bottle, this to be 
used only until the child is about three months old, when he 
can be taught to drink from a cup. If this be done, the 
child probably will not be a thumb-sucker. When a baby 
has its temporary incisors and one or more molars and is 
biting and chewing everything within reach it is evident that 
nature intended these teeth for use in masticating food. The 
mouth and teeth, to grow, must be exercised; and, as the 
child at this time is probably about nine to twelve months 
old, in addition to milk, starchy foods can be digested by the 
stomach. The top crust of bread, whole wheat, and so- 



Some Fundamental Observations. 21 

called graham bread, and such foods contain nourishment 
and possess just enough roughness to produce a laxative ef- 
fect. It is not advisable to give the child meat at this age, 
but bones free from gristle are appreciated by the baby and 
aid it in cutting teeth. 




Fig. 6. Dissected Superior and Inferior Maxillary Boxes, Showing 

Development axd Eruption of Temporary Teeth at the 

Age of 3% Years. 

Another mistaken idea is that because the child is drinking 
a large amount of milk he does not need any other liquid. 
Milk, while liquid at the beginning, is converted into a solid 
soon after it is swallowed. The child should be taught to 
call for water. A great amount of constipation in infants 
could be prevented if the parents would give them water 
frequently between meals. If we want to cause the child to 
become a so-called "bolter" of food, just keep on mixing 



22 



Practical Oral Hygiene. 



soups and patent foods that can be swallowed without chew- 
ing. All children want to crowd their mouths with food 
just as full as they can, but they can not swallow this without 
chewing. Therefore, give them food as dry as possible. 
Proper chewing not only causes the salivary glands to be 
developed, but also causes the development of the muscles, 
the jaws, and the teeth. 




Fig. 7. Dissected Superior and Inferior Maxillary Bones, Showing 

Development and Eruption of Permanent Teeth at 

the Age of 6 Years. 



The mother may talk about brushing the child's teeth 
all she wishes, she may brush them in spite of the tears and 
fighting, nevertheless, this will not have the effect of her 



Some Fundamental Observations. 



23 



example of brushing her own teeth In sight of the child. 
Example, with the child, creates an interest which certainly 
will become a habit later on. In the case of my own child, 
she will fight and scream if the nurse attempts to brush her 
teeth, yet, at the regular time, when the mother brushes her 
own teeth, the child will run into the bathroom and ask for 
a brush and will gladly follow the example. It is a lamenta- 
ble fact that so few mothers appreciate the importance of 
brushing and caring for the temporary teeth of the child. 
If the child cries when it eats sweets, or has the toothache 
at night, then the mother makes an examination of the little 




Fig. 8. Dissected Superior and Inferior Maxillary Boxes, Showing 
Eruption of Temporary and Permanent Teeth at 6 Years. 



24 



Practical Oral Hygiene. 



mouth, but if she could only realize it this cry of the child 
is the danger signal and it is too late to save the tooth. If 
the mothers would only realize how much suffering could be 
spared the little ones and how much better the dentist could 
make friends with the child, if no such painful cases of neg- 
lect were allowed ! When the child comes to us with the in- 
fected tooth, septic material forced into the surrounding 
structures, the tooth raised up in its socket too sore for us 
to touch, then it has to be extracted, or the child must go 
through an awful experience of having the cavity cleaned 
out and the tooth treated, which can never be forgotten. 




Fig. 9. Dissected Superior and Inferior Maxillary Bones, Showing 

Development and Eruption of Permanent Teeth at 

the Age of 11 Years. 



Sixth Year Molars. 25 

When we realize that carious temporary teeth almost al- 
ways must be sacrificed, and that carious permanent teeth 
sometimes cause the loss of life, it seems that these condi- 
tions would be reduced to the minimum and that, instead 
of waiting for the cries of the child and suffering so awful 
that the child becomes prejudiced against the dentist at an 
early age, the dental profession could be brought to give 
the youth of our land some sort of inspection, some system 
of supervision, which in the years to come would so im- 
press itself on the minds of the parents and teachers that, 
instead of the constant retrograde of the teeth, we should 
at least improve them to that degree which we find in the 
former races. Our children are born just as healthy as in 
prehistoric times. They have just as good bones, and, with 
proper instruction in oral hygiene, the teeth would be in 
accord with the rest of their bodies. 

Nodine calls attention to the fact that "an extensively de- 
cayed deciduous molar puts five teeth out of commission, by 
which the chewing apparatus is rendered ineffective, i. e., 
the decayed tooth, the tooth on either side, and the two 
teeth above." In the same paper, he also comments on 
the result of an examination made in the Breslau public 
schools for defects in speech, which showed that about half 
of these were of dental origin, either from decay, loss, or 
deformity. "For the correct pronunciation of certain 
sounds, deciduous teeth must be in their true position, neither 
decayed nor missing. Incisors are necessary for the pro- 
nunciation of the V sounds. . . . When the molar 
teeth are lost or pushed out of alignment, and the arches 
are contracted, a hissing sound is often produced. This 
lisping and hissing may be continued as a habit after the erup- 
tion of the permanent teeth." 

SIXTH YEAR MOLARS. 

Dr. Woodbury, of Boston, calls the sixth year molars the 
"working tools of mastication. Their work begins at once 



26 



Practical Oral Hygiene. 



and lasts throughout life; upon them rest full growth and 
development; upon them depends good health during life. 7 ' 
If this is true, we have the key-note for a great deal of 
dental irregularities due to mal-occlusion, food pockets, con- 
tracted jaws, and also a great many pathological conditions. 
One has only to examine the mouths of a moderate number 
of subjects to be astonished at the early removal of one or 
more of these sixth year molars. As these teeth come out 
just back of the temporary teeth, the parent is careless about 
the child brushing them properly, thinking that they, too, 
are temporary teeth to be soon shed. They are generally 
covered with a mass of sticky food which furnishes nutri- 
ment for germs of decay. (Fig. 10.) 




Fig. 10. A Normal Dentition at Seven Years. 
The Temporary Teeth 



A. Central ! 



B. Lateral 

C. Canine 



Incisors 



D. 1st 

E. 2nd 



> Molars 



The Permanent Teeth: 

G. 1st Permanent Molar, com- 
monly called the 6- Year 
Molar 
A black line marks the termination of the deciduous or milk teeth. 
Most mothers imagine that, because no baby tooth has been shed, 6, 
(the first permanent molar) is a temporary tooth. At seven years of 
age this tooth is often in such an advanced stage of caries that con- 
servative treatment is difficult if not impossible. (Pedley and Har- 
rison.) 

In examinations which I have made at the "Home for the 
Friendless," of children from six to fifteen years of age, in 



Sixth Year Molars. 



*7 



our city hospitals, and among students of the dental colleges, 
there is one defect more prominent than all others, and that 
is this condition of loss of the sixth year molars, especially 
in the lower jaw. If it were only the simple loss of the 
tooth, it would not be so bad. but nature, attempting to 
close up this space, tilts the next four or five teeth, causing 
them to get so far out of place that the proper mastication 
of food is impossible. 




Fig. 11. Models of a young; lady 21 years of age, showing mal-relation- 
ship of arches caused by early loss of lower six-year molars. (Case of 
Dr. Clinton C. Howard.) 



It should be the duty of all teachers of oral hygie: 
show on their screen pictures illustrating the result of this 
condition or to draw them on the blackboard. (Fig. n.) 

Dr. Porter, in an article published by the "Dental Hygiene 
Council." oi Massachusetts, says, in reference to the statis- 
tics which he reported in Brookline. Mass., "The sixth 
molar has aptly been styled by Dr. Bogue, the principal 
molar of man. All will, I believe, agree with this designa- 
tion. If the tooth is in large measure or wholly destr 
the efficiency of the teeth, as masticating powers, is largely 
lost. In 34; pupils, from eleven to fourteen years of age, 
iS per cent, had lost both crowns of the lower sixth 
molars, and 24 per cent, had lost one crown of a lower sixth 



28 



Practical Oral Hygiene. 



year molar. In the same number of pupils at the same age, 
6.9 per cent, had lost both crowns of their upper sixth year 
molars, and 13 per cent, had lost one crown of their upper 
sixth-year molars." (Fig. 12.) 



CHART SHOWING THE WANT OF MASTICATING 


POWER IN 


80 % OF CHILDREN AT 12. YEARS. 


1 

UPPER 






" PRE 
INCISORS* M oLARS MOLARS 


JAW. 






(ACE AT WMK.H 

! TVjy)c if _/£> My IS" 








I ,-Sv wa.- -rl^M 


J U1M£ OF 


TEETH) j 


V< ffil^HR 


ARTICULATION r" 

I TEETH 1 


i k ^ j 'KPm 


l 

■ 1 




m 7 


.LOWER 




. - j 


JAW. I 

V 




__ g .. DECAYED. F • 

ERUPTED | ERUPTED. PAINFUL § 

c: or u 
LOST 



Fig. 12. 



The best remedy is that described under "Technique of 
Prophylaxis," which is the covering of this tooth as soon as 
it erupts, but, as comparatively few people to whom we talk 
will be receiving regular prophylaxis care from a dentist, 
we should in all our lectures particularly stress the brushing 
of this tooth. 

MASTICATION OF FOOD. 

In our former races both the skulls of adults and of chil- 
dren exhibit a smaller number of carious teeth than we are 
accustomed to find to-day. This is undoubtedly due to the 
fact that they had coarse food to chew, for the cusps of the 
museum specimens are worn nearly to the pulp. Such a 



Mastication of Food. 



29 



thing in children to-day would be a dental rarity. Thus, we 
must conclude that it is the duty of the dentist to acquaint 
his patients with these facts and instruct them to provide 
their tables with some food which will require very thor- 
ough mastication. While such teaching may not at first be 
very popular, there are many of our good patients who 
would undoubtedly put this into practice if acquainted with 
the beneficial results which would surely ensue. 




Fig. 13. Dissected Superior and Inferior Maxillary Bones, Showing 
Development of the Permanent Teeth at the Age of 13 Years. 



It is unfortunate that the temporary teeth of our chil- 
dren, just at the stage when thorough mastication is of 
greatest importance, are allowed to decay to such an extent 



30 Practical Oral Hygiene. 

that it becomes a painful operation for the child to masti- 
cate food at all. It is at the age of from eight to twelve 
that the greatest developments should take place, but the 
examination of school children has shown that a large ma- 
jority of them are dental cripples. It is time for the dental 
profession to wake up to its opportunity and duty and to 
try to instil into the minds of their patients and the people 
at large these important facts about the care of the teeth 
and the prevention of disease. Instead of pies and soft 
foods the children should be taught to eat food which re- 
quires thorough mastication. I am always telling my stu- 
dents that the tough meat at the boarding houses is one of 
the greatest Godsends which they have, if they will only 
take advantage of it, and learn to thoroughly masticate their 
food. I have been told that some of them found a certain 
amount of consolation in the experiment. 

Nature furnished man's jaw with a series of muscles 
strongly attached to the jaw bones in order that the food 
might be given the proper amount of mastication. The 
muscles in this position are subject to the same laws of de- 
velopment and increase of power through exercise as the 
muscles in other parts of the body. It is a fact which can 
be easily demonstrated that the person who chews well has 
a much larger set of muscles than the person who chews 
but little. 

It has been shown heretofore that primitive man's im- 
munity from decay was due to the perfect mastication of his 
food. The one factor in our future work on prophylaxis 
which must be emphasized more than heretofore, is the use 
of our jaws. Dr. G. V. Black, in his book on "Operative 
Dentistry," describes an instrument, the gnathodynamo- 
meter, by which the force of the ordinary bite may be meas- 
ured. This has been found equal to three hundred pounds. 
Nature certainly intended us to make use of this tremendous 
power with which we are supplied. However, we are unfor- 
tunately not given this opportunity often, for our housewives 



The Neglected Mouth. 31 

would feel chagrined if there appeared upon our tables any- 
thing which would necessitate any large amount of chewing 
before it is swallowed. The whole idea of cooks seems to 
be to eliminate anything which requires much mastication 
and deprive us of this exercise which is so important to 
health and comfort. 

The idea is often held by the laity that the teeth are 
easily injured by the materials for cleaning and brushing 
them. Many patients, I have found, look with horror at 
the simple cleaning of the teeth, or the directions for use of 
a dentifrice, with the idea that the enamel of the teeth can 
be easily removed. This is one of the illusions that I first 
try to get out of the minds of the freshman dental students 
as well as the new patients who come for prophylaxis. They 
must be brought to realize that the enamel of the teeth is 
one of the hardest substances in nature and it is made to 
stand the hard usage that a life-time service demands. The 
abrasion that ensues from prophylaxis, the cleaning of teeth, 
and the brushing of teeth will not in any way measure up 
to that destruction which is sure to follow the lack of these 
precautions. 

THE NEGLECTED MOUTH. 

By an editorial in the Dental Dispensary Record (March, 
19 10) Dr. Belcher thus expressed himself: 

"A child can not be expected to develop into a healthy 
adult if he is deprived of efficient means of chewing his 
food properly, or if the food must pass through an uncared 
for mouth that is more like a cesspool than a receptacle 
for the transmission of food to the human body, every ounce 
of which must pass through this disease-breeding area on its 
way to the stomach, burdened with numerous colonies of 
poisonous germs, of which over twenty harmful varieties 
have been found in unclean mouths. No wonder such chil- 
dren are sickly and lacking in strength to resist disease, or 
that they are not considered bright and intelligent, and figure 



32 Practical Oral Hygiene. 

many times as members of our mentally deficient classes in 
the school work. Not only this, but an unclean mouth is 
the direct cause of many earaches, enlarged tonsils, ade- 
noids, stomach ills, and that most dreadful of children's dis- 
eases, diphtheria, is invited." 




Fig. 14. First Picture. — Child, age six, with full complement of decid- 
uous teeth. Note symmetry of features. 

Second Picture. — Same child. Picture taken three years later, dur- 
ing which time the four six-year molars were lost through neglect. 
Note mal-development of jaws, which is partially due to the absence 
of these most important teeth. (Case of Dr. Clinton C. Howard.) 



Under the title of "Clean Teeth on the Market," Dental 
Dispensary Record (March, 191 1), Dr. Agnes de Lima, of 
the Bureau of Municipal Research, of New York, says: 

"Doctors still prescribe tonics for invalids whose decay- 
ing teeth are draining their vitality, more than any other 
cause, and fortunes are spent to attempt to cure tubercular 
parents who reinfect themselves every time food, medicine 
and saliva pass over their diseased cavities and gums; mil- 
lions are spent on purifying the water supply and the soil; 
medical institutes are endowed to stamp out the contamina- 
tion of food and air by 'pathogenic bacteria,' but the prime 



The Neglected Mouth. 



33 



breeding place for germs — the human mouth — is neglected 
and uncared for." 

In the same journal (Nov., 191 2) Dr. H. N. Holmes 
writes some strong arguments: 

"When the slightest eruption of the skin occurs, no mat- 
ter what the cause, we begin treatment for it, and if it 
doesn't heal in a short time we consult a physician, and if 
he fails to get results, we are thoroughly aroused and seek 
a specialist without delay, but with the mouth it is quite the 
reverse. 




Fn;. 15. Same as Fig. 14 at age 18, showing progressive mal-develop- 
ment of the jaws, greatly due to the abscence of the "Keys to the 
Arches" — six-year molars. (Case of Dr. Clinton C. Howard.) 



"Not one person in twenty after the age of thirty has a 
mouth in a healthy condition, and not one in ten has a mouth 
free from pus at any time. 

"We wash our body once a day and our faces and hands 
several times, but, alas, some of us have our mouths cleaned 
once or twice a year — maybe. Even then it is seldom well 
done, for dentists as a rule slight such 'jobs,' for if the 
patients haven't enough decency, pride, self-respect or w T hat 



34 Practical Oral Hygiene. 

you may term it, for others, than to present themselves with 
a chloride of lime breath, far be it for the dentist to turn 
policeman at this age." 

Marshall, in his "Mouth Hygiene," calls attention to the 
fact that practically no one escapes the diseases of the mouth, 
and that dental decay is, without doubt, the most common 
disease that afflicts the human family. He further states 
that in his practice of about forty years, he has not seen but 
about four instances where persons had reached mature life 
without some form of dental decay. 



CHAPTER III. 
POPULAR LECTURES ON DENTAL SUBJECTS. 

"TEETH AND THEIR CARE/' LECTURE ISSUED BY MICHIGAN 
DENTAL SOCIETY. OUTLINED LECTURES BY DR. STEVEN- 
SON : (i) FOR MOTHER'S CLUBS, ( 2 ) TO CHILDREN, 
(3) FOR NURSES AND PHYSICIANS, (4) TO 

KINDERGARTEN. LECTURE BY 

DR. ALBRAY. 

The subject of oral hygiene is now causing such interest 
that even dentists in small towns are being called on to de- 
liver lectures before the various schools in their localities. 
This often places the dentist in a difficult situation, because, 
in the first place, the subject is new and he is often not ac- 
quainted with it. Dentists are not in the habit of writing 
papers and delivering lectures, and this new request, put be- 
fore them, sometimes startles them. Again the subject mat- 
ter is hard to collect and get in shape for a suitable lecture. 
*Many times I have heard of lectures that were utter fail- 
ures owing to the fact that they were too scientific and did 
not give elementary facts. Every dentist who does any 
lecturing along this line has been called upon by his various 
friends for facts which will constitute the right sort of lec- 
ture in this regard. With these facts before me, I have de- 
termined to give the frame work of some good lectures at 
some length, so as to meet this requirement. One of the 
best that was furnished me on this subject was sent in by 
the Dental Summary, issued by the Michigan Dental Society. 
While this lecture seems very elementary, it was delivered 
before the senior class of a high-grade female college, and 
the results which followed it show that it contained the 
proper material for this kind of lecture. The great trouble 



36 Practical Oral Hygiene. 

is that we forget how little the people know on this subject. 
This is one of the points which will have to be guarded 
against. This lecture and those following, are among the 
best which have appeared in dental literature. 

"TEETH AND THEIR CARE," LECTURE ISSUED BY 
MICHIGAN DENTAL SOCIETY. 

Recent examination of the teeth of school children in 
many parts of the world shows that about 96 in every 100 
children have diseased teeth. 

Think of it: Only about four children in a hundred who 
are not suffering more or less from diseased teeth. 

This would be bad enough if the toothache were all the 
little ones had to suffer as the result of somebody's neglect; 
but, as simply a matter of well-known fact, the toothache 
is the smallest part of the trouble. In fact, toothache is 
not the trouble at all, nor any part of the trouble; it is sim- 
ply the cry of the nerve, trying to arouse attention to the 
fact that something is wrong; the call of the nerve to be 
delieved from the poison that is killing it. 

Statistics show that on account of poor teeth the mental 
and physical development of the child is seriously retarded. 

The more the physical and mental development of the 
child is disturbed and retarded, the less is, of course, the 
general capacity of the child. 

The worse the teeth, the lower, as a rule, is the school- 
standing of the child. 

Dr. Luther H. Gulick, of New York City, is responsible 
for the statement that of 40,000 school children examined, 
those with two or more bad teeth averaged five months be- 
hind the grades that they should occupy, and would occupy 
were their teeth sound. Adenoids were responsible for lag- 
ging to the extent of eleven months. 

As decay spreads from the rotting apple to the sound one 
by its side, so does it spread from the first decayed tooth in 
the temporary set to the next and the next; and so does it 



Popular Lectures on Dental Subjects. 37 

spread from decayed first tooth to sound second, or perma- 
nent one, coming in alongside of it. In a very short time, if 
neglected, the second teeth are as bad as the first. 

Because of poor teeth, the child swallows its food un- 
chewed, and the habit of bolting is formed. The youth 
also, for the same reason, swallows his food unchewed, and 
the habit becomes fixed. The unchewed food is not di- 
gested; indigestion and bowel troubles follow, and the child, 
if it survive, becomes a weakly, undeveloped man or woman, 
an easy prey to tuberculosis and the host of other ills that 
prey upon people of low general vitality. 

This is no overdrawn statement; it is amply proved by 
experience and statistics. 

No claim is made, of course, that bad teeth are the sole 
cause of disease. Abuse, in like manner, any other part or 
organ of the body, as important as the teeth, and disease is 
sure to follow. 

Now, a very large part of this suffering — the half-starved 
body and the weak brain that follows it naturally grows out 
of pure neglect; and by far the greater part of this neglect 
is due to ignorance. And it seems strange indeed that the 
world should have been so tardy in realizing the importance 
of the teeth, and the necessity for their intelligent care. This 
condition of ignorance may be charged to what seems to be 
an innate tendency upon the part of scientific men generally 
to dig and delve in search of the obscure and the compara- 
tively unimportant, while overlooking the much more im- 
portant and perfectly obvious facts immediately under their 
observation. 

Let it be understood at the outset that a clean mouth and 
sound, well cared for teeth are positively essential to per- 
fect health; even to the average of good health; and that 
such teeth, used to masticate the food as intended by nature, 
will go a long way toward inducing and conserving that de- 
gree of health. 

If we would intelligently care for the teeth, w T e must first 
learn to know something about them; how r many there are 



38 Practical Oral Hygiene. 

in the first set and what they are; how many there are in 
the second set and when they are cut; the relation of the 
first set to the second, etc. 

It will, perhaps, help us to remember the number of the 
first or temporary teeth if we associate them with the fingers 
and toes. Ten fingers — ten temporary teeth in upper jaw; 
ten toes — ten temporary teeth in the lower jaw; five on 
either side, both in the upper and lower jaw. 

The first teeth are usually all in by the end of the second 
year. The first to be cut are the lower front teeth, the cen- 
tral incisors appearing, as a rule, about the seventh month, 
and lasting usually, until about the seventh year, when they 
are replaced by the permanent incisors. 

The incisors are the cutting teeth. From the same root 
word we have the word "scissors," you know. 

The other temporary teeth appear at short intervals, until, 
by the end of the second year, the entire twenty are in place. 

Now, it is of the utmost importance that these twenty 
teeth remain in place with their crowns undiminished in size 
by decay, until the permanent teeth are ready to replace 
them. The first teeth should be displaced and pushed out 
by the second or permanent set. Why is this so important? 
Many parents think that the first teeth amount to very lit- 
tle, and the sooner they are gotten rid of the better. There 
could not be a more serious mistake. Let us see. 

We already have considered the effect that decayed and 
aching teeth have upon the habit of chewing the food. Teeth, 
especially teeth that are just coming in, require exercise pre- 
cisely as do other parts of the growing body. When the 
first teeth are decayed, painful or lost, the permanent teeth 
do not have exercise they need, because the food is bolted; 
that is, swallowed without being chewed, or after being only 
partially masticated. And there is another reason why the 
retention of the first teeth is so important: 

About the time that the first front teeth are beginning to 
loosen, another tooth, the largest and most important tooth 



Popular Lectures on Dental Subjects. 39 

of all, is pushing its way up through the gum, right behind 
the first "baby molar," or double tooth. If this last baby 
tooth or those in front of it, have been made narrower than 
normal, or have been lost altogether on account of decay or 
premature extraction, this big, new tooth, which is a perma- 
nent one, the sixth from the center in front, and coming in 
at the sixth year of age, and not being guided into its proper 
place and kept there by sound first teeth, comes in out of 
place, too far forward. 

Sometimes it is the width of the tooth, sometimes the 
width of the whole tooth, too far toward the front. What 
difference does that make, some may ask? Isn't the tooth 
there? Will not the other teeth, coming in later, force it 
to its proper place ? No ; that's just the difference it makes ; 
that's just the trouble. 

When the first big, strong, permanent, most important 
tooth comes in too far forward, the jaw is shortened by 
just that much, and it remains too short. 

It is generally supposed that the jaw controls the location 
of the teeth in what is called the arch; that is, the semi-cir- 
cle in which the teeth are located; but that is only another 
of the many mistakes most people hold in regard to the 
teeth. The jaw does not control the teeth, but the teeth 
control the size and shape of the jaw. 

Now, into this shortened jaw, in front of the sixth-year 
molar, five permanent teeth must find a place. How are 
they going to do it? Well, most of you have seen mouths 
filled with crowded, jumbled, crooked, overlapping teeth; 
and that's how they do it. They come in where they can, 
following the line of least resistance, with nothing to guide 
them. (*) 

The sixth tooth, the six-year molar, coming as it should 
do and usually does, before the first or temporary teeth are 
lost, is usually regarded as a temporary tooth also, and is 
allowed to decay, even by parents who mean to give their 
children the best of care, under the mistaken impression that 



4Q 



Practical Oral Hygiene. 



it will soon be replaced by another and a permanent one. 
But it will never be replaced. The six-year molars, 
and all the other molars, are cut but once; once lost they are 
gone forever. They never will be replaced, except by arti- 
ficial substitutes, a very poor dependence at best. 

And this six-year molar is the most important of all the 
teeth. Upon its proper location and preservation depends, 
to a very large degree, the safety, the beauty and the use- 
fulness of all the other teeth. 

When the teeth are all in their proper positions, they form 
a beautiful even curve, the sort of curved line that nature 
delights in; and the features possess the contour and bal- 
ance that make the face so attractive. (Figs. 16 and 17.) 




Fig. 16. The Ideal Dentition, Buccal View. 



When the teeth are lost, or all jumbled together, the jaws 
are too small, the lips hang open, and the harmony of the 
face is marred, when not entirely destroyed. (*) 



Popular Lectures on Dental Subjects. 41 

There is, of course, a much more important phase of the 
subject than mere appearance, although that is certainly 
important enough, often making or marring the entire life. 
The more important fact is the use of the teeth as they 
should be used, to conserve health and strength of the entire 
body. 

When the teeth are all in their proper places, and stand 
at the proper angle with the jaw, the grinding surfaces of 
the upper and lower teeth fit together very closely; and, like 
the mills of the gods, they grind exceedingly fine, preparing 
the food as it ought to be for the digestive process that fol- 
lows. But if one is lost, especially if that one be this first 
permanent molar, the grinding surfaces drift apart; and, 
if the difficulty is not quickly and skilfully remedied, the 
work that the teeth should do, never can be done properly. 




Fig. 17. The Ideal Dentition, Lingual View. 



Then, too, of course, crowded and irregular teeth are 
much more difficult to care for, to keep clean, they are much 



42 Practical Oral Hygiene. 

more likely to decay, and the gums are much more subject 
to disease. 

Remember, then, that the tooth coming in at the sixth 
year, the sixth tooth from the center in front, is the first 
of the thirty-two permanent teeth, which, with the care that 
all of the teeth should have, ought to last each of us to the 
end of life. (**) 

If the child is to have strong, tough, resistant teeth, it is 
essential that its food contain an ample supply of the bone- 
building salts of lime. These salts are essential for other 
purposes as well. When it is known that the epidermis or 
skin, the bones and the teeth are all built of the same kind 
of cells, and that these cells depend for their perfection upon 
salts of lime, the importance of this kind of food readily will 
be recognized. 

The bottle-fed baby, brought up on the prepared foods 
so abundantly on the market at this time, starts life with a 
very serious handicap. According to the authority of scien- 
tific men, who are making these subjects the study of their 
lives, these prepared foods, nearly all of them, are altogether 
deficient in the bone-building elements. 

The best substitute for the nursing baby's natural food is 
cow's milk. Don't forget this; don't be deceived by allur- 
ing advertisements written by men who either do not know 
or care to know what they are talking about. 

The eruption, or cutting of the deciduous, or temporary, 
or first molars, indicates that the system of the child is ready 
to assimilate solid foods, and if he is given really solid foods, 
and taught to thoroughly masticate them, it will be well with 
that child. 

Every meal should contain something that requires good, 
vigorous chewing; like every other part of the body, the 
teeth, gums and jaws require and are developed by exercise, 
and suffer from lack of it. 

Among the foods rich in the bone-building phosphates of 
lime, wheat stands high. But, in the process of making 



Popular Lectures on Dental Subjects. 43 

fine, white flour, half of the lime-salts are lost and with- 
drawn with the bran. Whole-wheat bread, while usually 
not so easily digested, is a much better bone-builder, and any 
form of whole-wheat, containing every particle of the grain 
as nature makes it, is a perfect food, and should be largely 
used. 

No bread should be eaten until it is twenty-four hours 
old. Fresh bread, especially that made from fine, white 
flour, forms a soggy, fermenting mass in the stomach, and 
is not only very indigestible, but furnishes a breeding-place 
for the germs of fermentation, resulting in sour stomach, 
colic and many other ills. 

Whole wheat and whole wheat preparations, such as 
shredded-wheat, triscuit, etc., are excellent. Eggs, oatmeal, 
cornmeal, rice, and nearly all vegetables contain the lime- 
salts essential to bone-building. So, also, does beef. A 
simple diet , mixed, composed of the natural foods, will con- 
tain all of the elements necessary to good health and good 
teeth, provided they are well masticated, and provided also 
that digestion and assimilation are not impaired. 

Experiments made over and over again prove that ani- 
mals fed on poor foods, that is, such as are deficient in min- 
eral salts of the kinds necessary to body-building, have poor 
teeth and weak bones; and that, if such foods are continued, 
animals will starve to death rather than eat it. In this the 
animals are guided by a sure instinct that no amount of 
''tasting good" can deceive. 

Adding the necessary salts to the food artificially or giv- 
ing them in doses as medicines does not alter the case in 
the least. 

These experiments and their results apply equally to the 
child. If it is unable to obtain a sufficient supply of the 
necessary salts from a mixed diet of natural foods, the use 
of bone-meal, or the so-called bone-building drugs, is likely 
to prove of no avail. 



44 Practical Oral Hygiene. 

Whatever promotes good health — air, sunshine, nutri- 
tious foods well chewed, hygienic surroundings at all times, 
plenty of sleep, good habits, tends toward the building up 
of good, strong, solid, healthy teeth. 

Good teeth being acquired, good care is necessary in order 
to preserve them during life. If the teeth are not good, if 
they are soft, decay easily, or are lacking in any degree, they 
require even greater care than good teeth. With proper 
care, even poor teeth may be preserved almost indefinitely. 

Until within the last few years dentistry has concerned 
itself chiefly with repairing the damage done to the teeth 
by decay, and with replacing them with artificial substitutes 
when too far gone to be saved. 

To-day the aim of progressive dentistry is to prevent 
dental disorders rather than to cure them. 

To keep the teeth clean, highly polished, free from all 
sharp angles, irritating deposits, fields for the production 
of pathogenic or disease-breeding germs, or whatever tends 
to invite disease or promote decay, is the most useful field 
for the exercise of the best skill of the progressive dentist. 
In other words modern dentistry aims to put the mouth into 
hygienic condition and keep it there. 

The special method employed to bring about this natural, 
healthy, hygienic condition, and to maintain it after it has 
been brought about, is known as prophylaxis — oral prophy- 
laxis. Oral refers to the mouth; prophylaxis means ward- 
ing off or preventing disease; or that which makes for the 
preservation of good health. Oral prophylaxis then, means 
treatment that is efficacious in the prevention of dental dis- 
orders; of diseases of the mouth and the teeth, and of con- 
ditions in the oral cavity tending to cause diseases in other 
parts of the body. 

So important has this preventive idea become in the minds 
of the dental profession that there are now, in many cities, 
prophylaxis specialists, who devote their entire time to the 
practice of this important branch of dentistry. 



Popular Lectures on Dental Subjects. 45 

The creed of oral prophylaxis is that cleanliness is the 
salvation of the teeth; that a clean mouth and clean teeth 
mean a healthy mouth and sound teeth; and, as a natural 
consequence, a bettered, more resistant, physical condition 
generally. 

Based upon statistics, it is estimated that 72 men, women 
and children die every hour in the United States from dis- 
eases that might be prevented; and it is now known that 
many of these preventable diseases have their origin in an 
unhygienic condition of the mouth and teeth. 

The aim of oral prophylaxis is to do its share, and a large 
share, in the prevention of this needless loss of life; to bring 
about a condition of health and well-being so far as the 
mouth and teeth are concerned; to keep that part of the di- 
gestive tract that is under our control in a normal, healthful 
condition; and, with the help of the patient, to keep it there 
permanently. 

How is the patient going to do his share in the work 
of maintaining the health of the oral cavity? Certainly not 
by the ordinary thirty-second-lick-and-promise cleaning in- 
dulged in by the vast majority of people who use the tooth- 
brush. 

In the first place, it must be understood that the purpose 
of the cleaning is not merely to make the front teeth fit to 
be seen, but to make all of the teeth, on all of their surfaces, 
positively clean. And this means intelligent and conscien- 
tious effort, regularly and faithfully applied. 

To properly clean the teeth, begin by rinsing the mouth 
with salt water, about a teaspoonful of salt to a pint of 
water, warm or cold, as may be preferred, forcing it vigor- 
ously back and forth between the teeth. Do this with the 
same vigor and determination that you would put into doing 
anything that you thought would prolong your life, increase 
its happiness or usefulness, or increase your income. It is 
just as important as proper mastication, or as the proper 
setting of a broken arm. 



>£NTAL SCHUOt 



46 Practical Oral Hygiene. 

After using the salt water, put a quantity of good tooth- 
powder into the palm of one hand, with the other moisten a 
good tooth-brush with the salt water, and dip it into the 
powder. Then proceed to scour the teeth. 

Use the tooth-brush as you would a scrubbing-brush on 
your kitchen floor or in your bath tub. Scrub your teeth; 
do not be satisfied merely to brushly lightly over the sur- 
faces. 

Do not use the brush crosswise of the teeth. You will 
only touch the high surfaces that are naturally clean, any- 
how, and you may work great injury by sawing cavities in 
the teeth above the enamel, at the gum-line. 

Begin at the gums on the upper jaw and brush downward; 
begin at the gums on the lower jaw and brush upward; in- 
side and outside alike. As the inside or the tongue side 
of the teeth is harder to reach with the brush than the out- 
side, more time and care are necessary to get them clean and 
keep them clean. As a lamentable matter of fact, it must 
be said that because they are not seen they usually get much 
less care. Ignorance on this score is much to be lamented. 
A wealthy, prosperous and successful man of sixty, recently 
stated that until he was well past fifty, he never had tried 
to clean the insides of the teeth, thinking that they did not 
need any care at all. 

Scour the grinding surfaces back and forth, crosswise. 
Dip the brush into the powder often enough to apply it 
equally to all of the teeth, and remember that the surfaces 
that are hardest to reach need cleaning most. 

Make the cleaning of the teeth as necessary to your com- 
fort as the bath, or the washing of the hands and face. It 
is far more important. Take plenty of time. Ten to fif- 
teen minutes per day is none too much time to spend at this 
most important work; make work of it; make it a duty. 
The teeth should have three to five cleanings each day, in 
addition to the thorough scrubbing described. Remember, 
that the mouth is a veritable breeding-ground for disease- 



Popular Lectures on Dental Subjects. 47 

germs, and that they multiply with astonishing rapidity if 
undisturbed, while the raking and scraping given to them 
by the proper use of the brush, to say nothing of the fre- 
quent dosing with disinfectant germicides in the shape of 
tooth-powders and mouth-washes, prevent their increase 
almost wholly. 

Two or more tooth-brushes should be used, of a rather 
small or medium size, preferably those with wedge-shaped 
points on the rows of bristles, as the points work in between 
the teeth, where most care is necessary. Use your brushes 
alternately, so that they will have a chance to dry out before 
used again. Never buy a cheap brush. And never use a 
brush, no matter how much you pay for it, after the bristles 
begin to fall out. An over-used, soft brush, is the poorest 
kind of economy. After using the brush, rinse it thoroughly 
in the salt water and hang it on the rack to dry. Any good 
mouthwash will do in place of the salt-water. Powder need 
be used in most mouths but once each day, preferably at 
bed-time, if used as suggested. 

A larger proportion of the cavities in teeth start between 
them, where the brush, however skilfully used, can not 
reach. To thoroughly clean these spaces is, therefore, of 
utmost importance. For this, waxed floss silk, preferably 
flat, should be used. Insert between the teeth, and draw 
back and forth until all these surfaces are perfectly clean. 
Do this at least twice each day; better, do it after each meal. 

It is no easy matter to teach the children to keep their 
teeth clean, but the necessity of the case makes it the duty 
of every parent to keep constantly at their children until the 
habit becomes fixed. 

In spite of the best care we are able to give our teeth, 
deposits will slowly form on them in most mouths, and there 
will still be some decay. Therefore, it is necessary to visit 
the dentist at regular intervals. The frequency of these 
visits should be governed by the needs of the individual, 
and this should be left to the knowledge and judgment of 



4S Practical Oral Hygiene. 

the dentist. In very few cases should these visits be less 
frequent than twice each year. 

As to why teeth decay, an illustration may help to make 
the cause and process clear. If a drop of acid is spilled 
upon the marble top of a wash-stand, it boils and bubbles, 
and, if allowed to remain, will dissolve out the lime and 
leave the surface roughened. Nearly everybody is familiar 
with the experiment of soaking an egg in vinegar until the 
lime in the shell has been dissolved, and the egg, unbroken, 
then put into a bottle, having a neck half the normal size of 
the egg. Decav of a tooth is caused by a similar process 
of dissolving the lime. 

The lime in the tooth is eaten by an acid. This acid is 
known as lactic acid, familiar to nearly everyone. It is the 
acid present in sour milk. Its presence in the mouth is due 
to the fermentation or souring of food particles adhering 
to and between the teeth. 

In the mouth that is not cared for, the teeth are bathed 
in this acid practically all of the time, and all the time the 
acid is at work, dissolving out the lime-salts in the teeth, 
just as the acids do with the marble slab and the egg-shell. 
This shows why teeth start to decay at the points that are 
hardest to keep clean. It also shows why extra care should 
be taken to keep those points as clean as possible. Decay 
rarely starts on the exposed surfaces of a tooth. 

Now, as to the structure of a tooth. A tooth consists of 
the crown (the part above the gum), and one or more roots 
embedded in the jaw. The outer coating of the tooth, the, 
part that we see. is called the enamel. It is nearly all lime- 
salts, 9S per cent. It is very hard, very compact, com- 
paratively thin, and has no nerves: therefore, it is without 
feeling. Its purpose is to stand the wear of grinding, and 
to protect the softer, sensitive parts of the tooth beneath. 
(***) 

Beneath the enamel is the dentine. It forms the bulk of 
the tooth. It is only about three-quarters. 75 per cent. 



Popular Lectures on Dental Subjects. 49 

lime, and is, of course, not so hard as the enamel. It is 
something like bone, having tubes and hollow places, within 
it, along which the germs of decay can spread and multiply 
without much resistance. 

In the center of the tooth, surrounded by the dentine is 
the pulp, commonly but improperly called the nerve. It has 
a great many exceedingly fine, thread-like branches out- 
wardly through the dentine, forming a very complete signal- 
service, the duty of which is to warn us when danger from 
decay or other source threatens the health and usefulness of 
the tooth. (Fig. 18.) 




Fig. 18. Adult. Process and Part of Root Cut Away, Exposing 

Root Canals. 



50 Practical Oral Hygiene. 

A tooth that aches, after one has been eating, for in- 
stance, is a tooth in distress. Some of the little pulp- 
branches are exposed and are calling for protection. If they 
do not get it, the pulp itself will be calling next, and by that 
time the chances are that the labor, pain and expense of 
saving the tooth have been increased many fold. 

Here is a case in which a stitch in time may save not only 
a great deal of suffering, but, by a simple, inexpensive fill- 
ing, the tooth may be saved to usefulness and comfort. If, 
on the other hand, the warning is not heeded, the pulp, after 
protesting with all its might with some pretty severe aches 
and pains commonly called neuralgia and other things, gives 
up the fight and dies. Because the pain is felt not so much 
in that particular tooth as all over the face on that side, the 
tooth may not be suspected, and frequently physician's bills 
of large size are contracted in the vain search for relief. 

Facial neuralgia, so-called, of this character and from this 
cause, is very common. Facial neuralgia from all other 
causes combined is very, very rare. Therefore, when suf- 
fering from neuralgia in the face, suspect your teeth, and 
at once consult the dentist. 

It is a common notion that a tooth having a dead nerve 
or pulp can ache no more. This is a delusion. A dead 
tooth, like any other unburied dead thing, is dangerous, a 
menace to the health not only of the mouth, but of the. en- 
tire body. It is a breeder of poisonous germs. If these 
poisons escape into the mouth, they are mixed with the food 
and the saliva and swallowed. And, in the case of mouth- 
breathers especially, the foul gases created are carried to 
the lungs and thence to the blood, paving the way for tuber- 
culosis and a general undermining of the health. 

To one who knows how vile a dead pulp becomes, the 
very thought of having one in the mouth makes him sick. 
And how are we to have pure air in our homes, our schools, 
our opera-houses, our churches, when, with every breath 
from such a mouth, these poisons are poured into the atmos- 



Popular Lectures on Dental Subjects. 51 

phere? As a matter of simple self-protection, we should 
avoid inhaling the breath from such a mouth. 

If, instead of escaping into the mouth, the poisonous 
gases get out through the end of the root, the tooth becomes 
sore, the face swells, pus is formed and bores its way, 
usually with great pain, out through the jawbone and gum, 
forming the so-called gum-boil. This pus is also a poison, 
a dead thing; and this, too, is swallowed, making a much 
more serious condition than generally is known, or may 
generally be believed. No one can long be well under such 
a state of affairs, a veritable poison factory within the 
mouth. 

Many people are constantly ill, constantly under the care 
of the physician, doctoring for all sorts of troubles, who 
are simply the victims of blood-poisoning, due to neglected 
teeth. The troubles commonly called "nervous diseases" 
are largely due to these causes. 

Every year thousands of preventable deaths occur from 
causes originating in the condition described, although very 
seldom is the true condition suspected by anybody — except 
the dentist. He doesn't suspect; he knows. 

Offensive as is a tooth of this character and in this con- 
dition, and dangerous as it is to health and life itself, it may 
be restored to full usefulness, health and comfort. While 
it is very desirable to have the teeth frequently examined 
and all the cavities filled while small, a tooth is not beyond 
redemption and salvation even when nothing is left of it 
except the root, providing that root is firmly held in its 
socket. A root broken off level with the gums may be 
crowned so skilfully as to appear perfectly natural and defy 
detection, and it may be so applied as to be as comfortable, 
as serviceable, and, in many cases more lasting, than a well- 
cared-for natural tooth, that is perfectly sound. 

Another disease to which neglected teeth are subject, is 
loosening, due to deposits of lime in the form of tartar, and 
to collections of decaying matter, which are allowed to 



52 Practical Oral Hygiene. 

gather and remain on them. This causes the gums to 
swell, to become tender, to bleed easily, and gradually to 
waste away, together with the bony socket that holds the 
teeth in place. 

This is a very serious condition, not only preventing the 
proper chewing of the food, because of the tenderness of the 
teeth and gums, but the teeth themselves become exceedingly 
filthy, and in many cases large quantities of very rank pus 
are being continually swallowed, the health being thus most 
surely and certainly undermined by the two enemies, which 
ably aid and abet each other, one by preventing proper prep- 
arations of the food by the teeth, and the other by convert- 
ing much of it into rank poison. 

If this trouble is attended to in its early stages, it may be 
removed and the loose teeth tightened and restored to per- 
fect usefulness; but if neglected, the teeth finally will fall 
out, ending the chapter in disaster. 

Here, again absolute cleanliness is the great preventive. 
Teeth that are kept clean can not possibly get into this dis- 
tressing and often fatal condition. Here again, dirt, decay, 
degeneracy and death go hand in hand together. 

This disease, in common with most of those to which 
human flesh is heir, is much more easily prevented than 
cured. Those who are threatened with it or suspect that 
they are should lose no time in putting themselves under 
the care of a competent dentist, and then follow religiously 
and rigorously the instructions given. 

The expression, "My teeth are naturally so poor that I 
am going to let them go and have artificial ones," is very 
often heard from the lips of even comparatively young peo- 
ple; and, while it implies a compliment to the skill of the 
modern plate-maker, the thought back of it is usually a very 
unwise one to entertain, and the course a most foolish and 
unsatisfactory one to pursue. It is hard to imagine a set 
of natural teeth that are not or can not be made much more 
useful, satisfactory, sanitary and comfortable than the best 



Popular Lectures on Dental Subjects. 53 

plate ever turned out of a dental laboratory. This attitude 
has been responsible for the heedless loss of millions upon 
millions of perfectly sound teeth. It has come down to us 
from the days of our grandmothers; and while, in those days 
it may have been justifiable, in these days of advancement 
in dental science and practice, it is so no longer, except in 
very rare and exceptional cases. 

If the teeth really are too far gone to be saved, the sooner 
they are out and replaced the better; for, as stated, a mouth 
full of decayed and decaying teeth and roots is a menace 
not only to health, but to life itself. But let no one need- 
lessly sacrifice his own teeth for artificial substitutes. Good 
as they are now, most necessary in their place, and much as 
many of us owe to the advancement in dentistry during these 
last few years, they are but poor substitutes at best. 

You will be perfectly safe in trusting the judgment of a 
good dentist in such cases. The time has gone forever when 
a dentist would extract a tooth that might be saved, merely 
to satisfy the whim of a patient. Preservation and restora- 
tion of the natural teeth is the proper field for the exercise 
of dental skill; and few indeed, and daily growing beauti- 
fully fewer, are the dentists who do not recognize thrs fact, 
and conduct their practice accordingly. 

Another cause of poor teeth, crowded teeth, mal-formed 
jaws and unbalanced faces, with ill health and all the at- 
tendant train of suffering and inefficiency, is mouth breath- 
ing, due to a growth in the nose called adenoids. This is 
quite common in childhood, and is- very easily remedied; 
but, if neglected, means a weakened, impoverished body, 
subject to coughs and colds, throat and lung troubles lead- 
ing on to tuberculosis. Time will not permit going into this 
important topic in detail, but it is the duty of parents to 
watch their children, particularly while sleeping; and, if 
mouth-breathing is found to prevail, to consult a physician 
at once. 



54 Practical Oral Hygiene. 

Sucking thumbs and fingers in early childhood, the use 
of "baby comforters," rubber nipples or other objects held 
between the teeth, often produce serious deformities of the 
growing jaws, and should be avoided with far greater as- 
siduity than contagion from the simple diseases of child- 
hood. (****) 

Just a few words in conclusion : 

Don't forget that the first teeth are just as important 
while they last, as the second teeth, if not more so, for the 
position, soundness and value of the permanent teeth de- 
pend, very largely, upon the care that the first teeth receive. 

Don't forget the number of the first teeth; twenty in all, 
ten in the upper jaw, ten in the lower jaw, five on either side 
in both jaws. 

Don't forget that the sixth tooth, the six-year molar, is a 
permanent tooth, and is the largest and most important 
tooth in the entire set. 

Don't forget that clean teeth do not decay; that a clean 
tooth can not decay; and therefore, always remember to 
make every effort to keep the teeth clean — all of them, on 
all their surfaces, all the time. 

Don't forget that clean teeth, well cared for, and food 
well chewed, are essential to good health, a sound body and 
a strong mind. 

And do not forget that you are quite welcome to ask any 
questions on the subjects mentioned, if everything that has 
been said is not perfectly plain, simple and clear to you. 

Stars (**) indicate the advisability of introducing slides 
at points where they appear; or the slides may be left until 
after the lecture is concluded. 



OUTLINED LECTURES BY DR. STEVENSON. 

Dr. A. H. Stevenson, published in Oral Hygiene the fol- 
lowing outline lecture, used by the Committee on Public 
Health and Education of the Second District Dental So- 
ciety of New York: 



Popular Lectures on Dental Subjects. 55 

In order to obtain uniform results, we prepared lecture 
outline forms to cover our most common types of audiences. 
Three of these I append. They are merely guides for the 
lecturer, and give him ample opportunity for originality, 
as may be seen. 

FORM I. 

OUTLINE OF LECTURE TO MOTHERS' CLUBS. 

The following points seem to be the ones that need the most em- 
phasis: 

1. Show that the Subject of Mouth Hygiene is not simply a hygiene 
of the teeth alone, but of the body, and that the responsibility for the 
general health of the child depends mainly upon the mother, and she 
should have sound ideas of how to conserve the child's health. 

2. Bring out the influence that sound, clean teeth have upon the 
general health of the child. 

a. Show how diseased and unclean teeth play a large part in 
the causation of disease. That the method of infection in the 
following diseases is chiefly through the mouth: Tuberculosis, 
pneumonia, influenza, la grippe, diphtheria, measles, scarlet fever, 
mumps. 

b. Show how lack of, decay, or irregularity of the teeth cause 
mal-nutrition, mouth-breathing, adenoids. 

c. Show how the pain of diseased teeth may be reflected to the 
eyes, ears, face, neck, head, and other parts of the body. 

3. Show how the temporary teeth develop and then the permanent 
ones. (Use Charts.) 

The use of cotton on the newly erupted teeth of infants. 

4. Show the importance of preserving both. 

Lay particular emphasis upon the six-year molar. 

5. Function. — Tell how the teeth improve with use and advantage 
of thorough mastication. 

6. Conclude with general mouth hygiene, as follows: 
Articles required: 

Brush — Size and shape, cautioning against too large a size. 

Floss — How to use. 

Dentifrice — Warning and advice. 

Method of Brushing — Circular motion, including gums as 

well as teeth. 
Frequency — After every meal and before retiring. 
Rinsing — With lime water solution. 
N. B. — Use simple language and avoid technical terms. At the 
close of the talk invite the mothers to ask questions. 



56 Practical Oral Hygiene. 

FORM II. 
OUTLINE OF THIRTY MINUTE TALK TO CHILDREN. 

1. (For boys.) Show how success in sports and life depends upon 
good health. 

(For girls.) Show how success in singing, reciting, or any public 
appearance depends upon good health. 

Show that good health is impossible without clean mouths and 
good teeth. 

2. Explain the relation of sound, clean teeth to strength, endur- 
ance, grace, beauty, and class-standing. 

3. State briefly how decay is produced and how it extends, using 
illustrations, if possible. 

Show that gelatinous placque precedes decay, and that destruction 
of placque means prevention of decay. 

4. Emphasize the importance of preserving the temporary teeth, 
and the sixth-year molar. 

Introduce phrase, "A clean tooth never decays." 
Have children repeat it in unison. 

5. Explain the dangers of bolting food, and the advantages to the 
teeth and body in general, of thorough mastication. 

6. Conclude with general mouth hygiene, as follows: 
Articles Required: 

Brush — Size and shape, bristles. Caution against very large 

brushes. 
Floss — How to use. 
Dentifrice — Warning and advice. 
Method of Brushing — Demonstrate circular motion. 
Frequency — After every meal and before retiring. 
Rinsing — Using lime water solution. 

FORM III. 
OUTLINE OF LECTURE TO NURSES AND PHYSICIANS. 

The following points seem to be the ones that need the most em- 
phasis : 

1. Show how unclean mouths are ideal mediums for the prolifera- 
tion of bacteria, there being present necessary elements: Moisture, 
Darkness, High Temperature, and Pabulum (or the debris). The 
last can be avoided. Indicate the following as diseases whose main 
means of infection is the discharge of the mouth. Tuberculosis, 
pneumonia, influenza, la grippe, diphtheria, measles, mumps. 



Popular Lectures on Dental Subjects. 57 

Show how lack of, impairment or irregularity of the teeth cause 
mal-nutrition, mouth-breathing, adenoids. 

2. Give brief histology and development of the teeth, temporary 
and permanent, showing how calcification proceeds and dietetic in- 
fluences. (Use Charts.) 

Discourage the use of glass tubes for administering drugs, and ad- 
vise capsule or tablet form for all administrations of tine, of ferric 
chloride. Emphasize that dilution increases destructive strength of 
this drug on the tooth structure. 

3. Show prevalence and nature of dental caries as a disease itself, 
and conditions favorable for its inception and increase. Show how 
reflexly disorders of the eye, ear and brain may result. 

4. Give general mouth hygiene for normal conditions indicating: 
Articles Required : 

Brush — Size, shape and bristles. 

Floss — How to use. 

Dentifrice — Warning and advice. 

Method of brushing. 

Rinsing — With lime water solution. 

5. Give the application of the hygiene by nurses, emphasizing: 

a. The preparation of patients for operations (through oral 
asepsis). 

b. The care of the mouths during pregnacy. (Beware of 
extreme oral acidity.) 

c. The care of the mouths of children. (See Form I.) 

d. The care of the mouths of invalids and convalescents. 
(Rigid hygiene.) 

6. Conclude with the importance of strict oral cleanliness on the 
part of the nurses as a safeguard against infection for themselves, and 
those for whom they care. 

FORM IV. 
OUTLINE OF LECTURE TO KINDERGARTEN CHILDREN. 

Open talk with either story* or demonstration* to attract atten- 
tion, and then proceed with the following: 

1. Describe graphically the doorway and vestibule of a house, and 
the effect on the interior of that house, be it ever so neat and clean, 
of a dirty entrance with children passing in. 

2. Show the analogy of the mouth as the doorway and vestibule 
of the body, and the effect on the interior of the body of an unclean 
mouth with food passing through and carrying filth into the stomach. 

Results: Disease and illness; loss of play and school. 



58 Practical Oral Hygiene. 

3. Ask how many children washed their faces before coming to 
school. (Usually unanimous.) Then show the importance of clean- 
ing the ''inside of the face," in order to be clean and well. 

4. Very briefly, with a large model, if possible, show the alignment 
of the teeth. Promise that if they keep them clean they will stay 
pretty and white as snow. 

5. Conclude with simple mouth hygiene, demonstrating with giant 
tooth-brush on model, and emphasize the frequency of this operation 
and the use of a dentifrice. 

^Example. — Ask the conundrum: "Twenty white horses on a red 
hill, here they go, there they go, now they stand still." Answer — 
The teeth. 

t Select a precocious-looking child and with a new brush show him 
how to brush his teeth, while the others are looking. 



FORM V. 
SYNOPSIS OF PUBLIC LECTURE. 

MOUTH HYGIENE. 

I take it for granted that all want to live to a good old age. 

There are men throughout this country who are trying to prolong 
life — your life — by preventing disease. 

It is a significant fact that there were but sixty-one persons who 
died last year to every one hundred who died in 1878, thirty-five 
years ago, a saving of 44,115 lives in New York City alone. 

To do real damage, disease must enter the body. How do most 
of the contagious diseases find their way into the system? Through 
the door-way — the mouth. 

It is common knowledge that disease germs can neither thrive nor 
survive unless unclean conditions exist. How is it in your mouth? 

There are three things necessary to sustain life — food, water and 
air. All of the food, all of the water and part of the air enter the 
body through the mouth. Hence, the importance of absolute cleanli- 
ness at all times. 

The effect of the most stringent pure food law is lost unless the 
mouth is clean, as the law does not control the food after it has passed 
the lips. If allowed to remain in the mouth, food becomes polluted 
worse than any form of adulteration. 

Wherein lies the remedy? In practical mouth hygiene. 



Popular Lectures on Dental Subjects. 59 

HYGIENE. 

Clean the mouth oftener and clean it better. 

Brush the teeth whenever they are unclean, after every meal and 
the last thing at night. 

The brush should not be too large, and should be slightly curved, 
as is the arrangement of the teeth. Medium stiff bristles will be 
found best for most people. 

Dentifrice (powder or paste) should not be too gritty. 

Dental floss should be carefully used for interspaces. 

In brushing use circular motion, including gums as well as teeth, 
and remember that there are inner as well as outer surfaces. 

Masticate thoroughly, for, like the muscles, the teeth improve with 
use. 

These rules of mouth hygiene, although simple, are effective. Make 
them a habit and increase your immunity to disease. 

FORM VI. 
SUGGESTIONS FOR BRIEF TALK TO BOY SCOUTS. 

Commence by referring to the great Enemy of the Human Race, 
Disease. 

Compare this Enemy to an invader during a campaign, and point 
out how a General defending a city would fortify the gateway first. 
Thus bring in the Mouth as the gateway to the body. 

As the soldier has weapons and powder, show that we have weap- 
ons (brushes) and powder, and that the intelligent use of same re- 
sults in the destruction or crippling of the Enemy, Disease, in this 
region. 

In this manner build up a respect for the oral cavity, and at the 
conclusion of talk demonstrate the Tooth Brush Drill. 

When possible it is wise to have the boys notified to bring their 
brushes for the occasion, and a few taught the drill in view of the rest, 
the entire troop finally performing it. 



LECTURE BY DR. ALBRAY. 

Forceful illustrations count for more in a popular lecture 
before a general audience than do statistics or pictures of 
anatomy. For an audience of girls or ladies, what could 
be more convincing than the following extract from a lec- 
ture by Dr. R. A. Albray, published in the New Jersey 
Dental Journal: 



60 Practical Oral Hygiene. 

Teeth are for use and that use is to break up the food, 
incorporate the saliva with it, and so begin the process of 
digestion. The proper mastication of food is the first step 
toward its digestion and subsequent assimilation. The food 
is the material which nourishes and sustains the body, it be- 
comes part of the body itself. Do you not see then how 
important it is that this food be properly prepared by the 
teeth for the further processes of digestion? In making 
a cake you would not put your flour, butter, sugar, baking- 
powder, eggs and flavoring in a pan and then into the oven, 
without properly mixing it, and expect it to be a good cake. 
All of the ingredients are there for a good cake, but unless 
the mixing process is properly done, some one of the family 
would want to know when bricks had been added to the 
menu. Just so with the body, you can give the child, or the 
adult, plenty of good food, and the ingredients are there to 
nourish the body, but if the mixing is not properly done the 
result is like the cake, not as good as it might have been. 
During childhood the bodily weight must not only be sus- 
tained, but it must be greatly increased each year. We 
adults have only to assimilate enough food material to re- 
place the tissue lost by use. How much more necessary 
then is it that the child's digestive system be in good work- 
ing order? 

If a child comes to school and is found to have head lice, 
the school physician or nurse is immediately concerned and 
prompt measures are instituted to correct the trouble, when 
about the worst these little creatures can do is to cause a 
good big case of itch. If another child has a conjunctivi- 
ties, home it goes until it is cured; another may have a ring 
worm or a dirty face, but until the condition is corrected to 
the satisfaction of the school authorities, the child can not 
return to school. This is alL very fine and I have nothing 
but commendation for the medical inspection. But what 
of the child with a filthy, dirty mouth, full of active, disease- 
producing bacteria; foul breath polluting the school room, 



Popular Lectures on Dental Subjects. 61 

and every cough or sneeze sending bacteria into the air by 
the thousand? Why, in most communities it stays in school 
and makes a present of these "bugs" to the other children. 
Nothing is thought of it; dirty, unsanitary mouths are the 
rule, most people have them, and most of them would rather 
spend an hour in washing the face, combing the hair, and 
manicuring the nails, than to spend a few minutes with a 
tooth brush, and an hour or so in the dental chair every few 
months. All vanity and ignorance. The state of the 
mouths of the school children is deplorable, and the only 
remedy is to educate them to a realization of the necessity 
for its correction. Daily brushing of the teeth, regular 
visits to the dentist, combined with dental inspection in the 
schools, with the inspector invested with the authority to 
compel the child to have its mouth put in a sanitary condi- 
tion is imperative, and it is the only way in which the health, 
physical, mental, and moral ideals of development can be 
attained. 



CHAPTER IV. 
POPULAR LECTURES— CONTINUED. 

AN ILLUSTRATED LECTURE BY DR. ZARBAUGH. LECTURE 

FOR SCHOOL CHILDREN FROM FOURTH TO 
EIGHTH GRADE, BY DR. CORLEY. 

If it is convenient to obtain the lantern and proper slides, 
the following lecture by Dr. L. L. Zarbaugh, can be used 
to advantage. The cuts suggested are easily made and 
show to good advantage. While the article was written 
on the subject of "Moving Pictures in Dentistry," I have 
moved it around a little so that it will fit the subject. 

AN ILLUSTRATED LECTURE BY DR. ZARBAUGH. 

Open with a home scene, showing family group, children 
playing or reading, mother sewing or darning, father read- 
ing the evening paper. He reads an article, "The time to 
begin to care for teeth is in childhood," etc. Father calls 
mother's attention to the article, which is then shown on 
the screen. They then look at the children's teeth, and de- 
cide then and there to instruct the children in the care of 
their teeth. 

Next is shown a dental nurse or dentist instructing the 
children in the proper manner of caring for the teeth, the 
use of dental floss, the folly of blunt wood toothpicks, etc., 
the correct method of brushing the teeth, etc. 

Then follow with a short, "cute" picture of "the baby" 
brushing his teeth, as the dentist has directed. 

Other subjects will be the interior of a school-room, 
showing the examination of school children's teeth, showing 



Popular Lectures on Dental Subjects. 63 

that the instruments are sterilized after each child — a near 
view of just how it is done; also showing a near view of 
20 boys and girls, showing only the mouth and teeth, and 
pointing out the decayed teeth in each mouth and other 
defects as they exist. 

Show the number of percentage of 20 children needing 
dental services. It should be vivid and convincing, and will 
go a long way towards removing the prejudice existing in 
the minds of many members of school boards and teachers 
against it. This part of the lecture will awaken such an 
interest on the part of the public that they will demand the 
examination of school children's teeth — the very thing we 
are striving for; and the best way to get into the schools is 
to create an interest in the public mind, which will soon 
grow into a demand. 

Then show a near view of an unhealthy mouth, loose 
teeth, tartar, pus, etc. Move the loose teeth with an in- 
strument; show the ruin that neglect will cause in a mouth; 
then show this same mouth as it will appear a short time 
later, unless cared for, as barren of teeth as the mouth of 
a new baby. 

Next show the progress of decay, by picture or black- 
board illustration, in a tooth from the very start until the 
death of the dental pulp, the breaking down of the enamel, 
etc. This will be done mechanically; the decay will be seen 
moving towards the pulp; the period or time at which the 
tooth begins to ache will be pointed out, etc. Some of the 
text, no doubt, will be along the following lines: (Fig. 19.) 



64 



Practical Oral Hygiene. 





SHOWNG FOOD PARTICLES. WHICH ' EEPAfEHTM.FDfiMACID Cacid attacking WE lime in the enamel rods 





showing- deca y attacking dentine further Progress of Decay - Tooth begins 70/lcfe 



UNDERMINING AND BREAKING DOWN «™ ENAMEL . YW5 DEATH OF DENTAL PULP OR NERVET 





Exposing LatyCdvity which has been fbrminj^nsuspecied, for Months. Formation of PUS and GAS in Pulp Lhamber 
Fig. 19. Showing the Various Steps in Tooth Decay. 



Popular Lectures on Dental Subjects. 65 

No. 1. Uncared for teeth, showing food particles, which, 
fermenting, form acid. 

No. 2. Showing the acid attacking the lime in the 
enamel rods. 

No. 3. Showing decay attacking dentine. 

No. 4. Showing further progress of decay; tooth be- 
gins to ache. 

No. 5. Showing undermining and breaking down of 
enamel walls, exposing large cavity which has been forming, 
unsuspected, for months. 

No. 6. Showing death of dental pulp, formation of 
gas, pus, etc., in pulp chamber; escape of gas at apex, swell- 
ing, abscess, etc. 

It has been suggested that inasmuch as we show the death 
of the pulp, for a change, and to give the people a chance 
to relax a little, we show the funeral of a dental pulp, with 
the owner of the tooth as chief mourner. Worked up prop- 
erly it would be very funny and make the people in the 
theatre wonder just how long they will dare to wait before 
they, too, will have a funeral of their own. 





Showing* growth and multiplication of 

bacteria in such a tooth in 24- hours. n . , n - 

Growth of bacteria is shown in motion, fonts Usually Mej/ecfeo in Brushing Whw Day B$in 

Fig. 20. Showing the Steps in Tooth Decay. 



Fig. 20. A badly decayed molar, showing the growth of 
bacteria in such a tooth in 24 hours. The multiplication of 
germs also will be shown in motion and will teach such a 



66 Practical Oral Hygiene. 

lesson that anyone seeing it, who has a decayed tooth, will 
not go to bed without making some effort to clean it up. 
When we consider the appalling rapidity with which bac- 
teria multiply we can realize how interesting this picture is 
sure to be. According to Conn, professor of biology at 
Wesleyan University, "it is the power of multiplication by 
division that makes bacteria so significant. This power of 
growth is almost incredible. Some species divide every 30 
minutes, or even less. At this rate each bacterium would 
produce, in a single day, more than 16,500,000 descend- 
ants; in two days about 281,500,000,000, or about one solid 
pint. At the end of the third day, unless checked, the 
product of one original bacterium would weigh about 16,- 
000,000 pounds. Of course, this growth is only theoretical, 
as under no conceivable bodily conditions could it go on 
unchecked." 

Tell about a boy who would not clean his teeth; show him 
going to bed with the toothache (making a striking example 
of him), show the usual fuss, hot water bottles, etc.; then 
show a dream that he has while in bed; he dreams of a 
trip to the dentist, as he supposed it would be. Very funny, 
of course, yet so arranged as not to bring criticism on the 
profession or detract from the real purpose of the lecture. 
Then after the nightmare, a trip to the dentist as it really 
was; show him treated kindly and relieved of his suffering, 
etc. State that fear and ignorance cause more pain and 
keep more people from visiting the dentist than any other 
one thing. 

Next tell the good resulting from care of the teeth; show 
a healthy mouth from childhood to old age; show teeth 
without a blemish, every one sound, without even a filling. 
This, too, will teach a great lesson and make a lasting im- 
pression. 



Popular Lectures on Dental Subjects. 67 

LECTURE FOR SCHOOL CHILDREN FROM FOURTH TO 
EIGHTH GRADE. 

Compiled by Dr. J. P. Corky. 

Star (*) indicates the advisability of introducing slides at points 
where they appear; or the slides may be left until after the lecture 
is concluded. 

We have a great many good things in this life, but the 
greatest possession of all is good health. Health is more 
important to children than to grown up people, because if 
one is not well while he is growing, he will not have a 
strong vigorous body when he becomes grown up, and he 
will be more apt to have all kinds of diseases during the 
rest of his life. 

Clean, wholesome, well-prepared food has more to do 
with the health of a child than any other one thing. If food 
is clean and wholesome, but is taken through a mouth which 
is unclean and unwholesome, it will not be clean and whole- 
some when it goes into the stomach. 

(*) This first picture shows a man with his front cut 
away, showing the canal through which the food passes into 
and out of the body. The large hole which we see at the 
top of the canal is the mouth. If the food is clean and the 
mouth is clean our stomachs will get clean food, but if the 
mouth is filthy, the food will surely be made filthy before 
it is swallowed. A great many germs, such as diphtheria, 
scarlet fever, typhoid fever, and tuberculosis, are frequently 
found in mouths which are habitually unclean and full of 
decayed teeth. 

Some times, after a person gets well of a disease, he will 
carry the germs of this disease in his decayed teeth, and by 
spitting, and various other ways, give the disease to other 
people. 

(*) This is a toothless pair. Old "Mammy" has lost 
all her teeth and the "baby child" has not gotten hers; at 
least, we can't see them, but if she should scald her little 
mouth bad enough for the gums to come off, we would see 



68 Practical Oral Hygiene. 

a row of sacks just under where the teeth will peep through 
when they come into the mouth. 

(*) Just inside of this row of sacks there is another row 
of smaller sacks. If we should slit open one of these sacks 
what do you think we would find? The top of a beautiful 
little tooth like a bulb, which in the spring time peeps up 
through the ground and opens into a beautiful flower. This 
tooth is pretty and clean and hasn't a decayed spot about 
It, and if it is kept clean as long as it remains in the mouth, 
it will never decay. The baby ought not to suck her thumb 
or keep a pacifier in her mouth all day, because this will 
mash these little sacks out of place and will make her teeth 
crooked. (*) It will also change the shape of the soft 
bones of the front of the face and make her little nose turn 
up like this. (*) So, if you don't want the baby's nose to 
turn up, you had better tell your mother not to let her suck 
her thumb. 

(*) The picture on the left shows the upper part of the 
mouth of a child two and a half or three years old, with 
all the first set of teeth in place. You see that they are all 
sound and regularly arranged. There is never a crooked or 
misplaced tooth in the first set, but there are frequently 
misplaced teeth in the second set. The most common cause 
is that the mouth and jaws have not grown large enough 
for the second set. Chewing is what makes the jaws grow, 
so if your teeth are crowded and crooked, it is because you 
didn't chew with your first set. Sometimes, as we will see 
in a moment, other things keep the jaws from growing and 
misplace the tooth, but the lack of chewing is the main 
cause. The picture on the right shows the same case at 
about six years old. It has another group of teeth. They 
belong to the second or permanent set. If you lose these 
you will never get others to take their places. They are 
called the sixth-year molars, and are the largest and most 
useful teeth in the mouth. They are more frequently de- 
cayed than any others for the reason that boys and girls at 



Popular Lectures on Dental Subjects. 69 

six to nine years don't usually keep their teeth clean. The 
mother usually thinks these teeth are part of the first set, 
and thinks it does not make much difference if they are lost, 
but we will have more to say about these teeth in a moment. 
You will notice that one of the front teeth is missing. Do 
you suppose the dentist had to pull this tooth because it 
ached? No. 

(*) It just dropped out and "didn't hurt a bit." I am 
going to show you why it dropped out. 

(*) In this picture the bone has been cut away from 
the root of the temporary teeth and we find that just above 
each little temporary tooth there is a big permanent one. 
The permanent tooth comes down upon the end of the tem- 
porary tooth and nibbles it off as a mouse nibbles cheese, so 
that by the time the permanent tooth gets ready to come 
into the mouth the temporary tooth has lost its root and 
drops out. But I am going to tell you something which I 
want you to tell your mothers. If the temporary tooth is 
allowed to decay until it aches, the permanent one will stop 
nibbling and you will have to go to the dentist and have 
him grind it down to the gums so that the new tooth can 
push it like you would drive one nail out with another. This 
is one reason why the temporary teeth should be kept clean 
and free from decay. Another reason is that you can't chew 
so well if your temporary teeth are decayed. Your jaws 
will not grow and be large enough for the permanent teeth, 
and you will suffer from indigestion and its consequences. 
It will also be impossible to keep your mouth free from 
germs and the new teeth will decay as soon as they come in. 

(*) When one is four years old the teeth are close to- 
gether, but if the jaws are properly used in chewing, they 
begin to separate as the jaws grow, so that by the time one 
is six years old, the teeth do not stand apart as they do 
in this picture. 

(*) The dentist should put in a little appliance to spread 
the arch, otherwise the permanent teeth will be crowded. 



70 Practical Oral Hygiene. 

(*) This man didn't chew his food when he was a boy. 
I guess he just gobbled it up with both hands like this (Illus- 
tration), so his mouth didn't grow and his teeth were all 
awry. His mouth and face didn't grow either, so he had a 
big head and a little pinched face. 

(*) This man chewed his food when he was a boy, and 
when he grew to be seventy-five years old, he had all his 
teeth and was a good-looking, hearty old man. I guess he 
just chewed and chewed and chewed, until the food just 
swallowed itself. You needn't bother about swallowing 
your food. After it has been sufficiently ground, it will slip 
down without any effort. 

(*) This is the lower set, and they are just as fine as 
the upper. Those dark lines which you see marking the 
tops of the back tooth are grooves, which divide the top 
or grinding surface of the tooth into points and depressions. 
By this arrangement the free surface of the tooth is in- 
creased and its unevenliness makes it a much more efficient 
grinder. 

(*) This is the same case with the teeth brought to- 
gether. Notice how beautifully they fit, and also that each 
upper tooth touches two lower ones. Which one of these 
teeth could one afford to lose? 

If you should saw through a front tooth and through 
the gum and bone to the end of the root, you would find 
that the tooth is made up of four different substances. The 
one which covers the top is enamel, and it is the hardest 
organic substance in the world except diamond. The next 
substance which makes up the bulk of the tooth is dentine, 
which is not so hard and wears and decays more rapidly. 
Encasing the root is a still softer substance called cementum. 
Occupying a canal in the center of the tooth is the pulp, 
which is composed of blood vessels and nerves. When de- 
cay makes a hole through the enamel and dentine into this 
pulp, the tooth begins to ache. Surrounding the root and 
attaching it to the gum and bone, is a thin membrane — the 



Popular Lectures on Dental Subjects. 71 

peri-cementum. If you allow tartar to accumulate on the 
teeth and remain for a long time, it will destroy this mem- 
brane and the tooth will loosen and drop out. Teeth are 
lost mainly in two ways — by decay, which destroys their 
crowns, and by disease of the gums and destruction of the 
peri-cementum. Both of these causes can be prevented by 
yourself, and I am going to tell you how you may do it. 
We will first tell you how to avoid diseases of the gums. 

(*) If you will examine your teeth when you first get 
up in the morning, you will find them covered with a thin, 
soft, yellowish deposit, which you can scrape off with a tooth- 
pick and examine. It looks like cream, but it doesn't taste 
like cream and it doesn't smell like cream. It is composed 
of epithelial cells, which shed from the lining of the mouth, 
mucus and microscopic granules of lime from the saliva, and 
if the mouth has not been cleansed of food before retiring 
it will contain decayed particles of food. If you do not 
brush this deposit off carefully before eating, the food will 
strip it down over the tooth and pack a little ring of it under 
the free margin of the gum. If it is allowed to remain there 
for a very long time, it becomes so hard that only the den- 
tist can remove it, and it will cause the gums to inflame. A 
little is added to it every day, and by and by the entire root 
will be covered and the gum destroyed. 

(*) This is practically the same thing which causes dis- 
ease of the gums. 

(*) See this deposit on the side of the tooth on the 
right. In the picture on the left, this deposit has been re- 
moved, showing how much of the membrane has been de- 
stroyed. 

(*) The tongue side of the lower front teeth is the most 
favorite place in the mouth for the accumulation of this 
deposit, partly for the reason that a great quantity of 
saliva is poured out at this point, but principally because 
these surfaces are not properly brushed. 



72 Practical Oral Hygiene. 

(*) This shows a deposit on the cheek side of the upper 
back teeth, which is also a surface not usually reached with 
the brush. 

(*) After the gums have gotten as bad as this, there is 
no way to save the teeth, and they will soon be dropping 
out. Remember that this disease of the gums can be pre- 
vented by thoroughly brushing the teeth twice a day. We 
will show you in a moment how to brush them thoroughly. 
Let us now take up decay, which is the other great disease 
of the teeth, and we will then show you how both may be 
prevented. 

(*) If you will examine the tops of the back teeth im- 
mediately after eating you will see that the little grooves 
which mark their surfaces, are filled with food. At first 
the food is granular and may be removed easily. Usually 
a vigorous rinsing of the mouth is all that is necessary, but 
if it is not removed at once it begins to ferment and develops 
a muculaginous condition, which makes its removal much 
more difficult. During the process of fermentation, an acid 
is produced which dissolves the enamel. This is about the 
only thing which causes teeth to decay. Hence, if no food 
be allowed to remain in the mouth until fermentation occurs, 
there will be no tooth decay. 

(*) In tooth No. i the decay is very small. The point 
where it made its way through the enamel is scarcely larger 
than the head of a pin, but you can see that it is much larger 
in the dentine than it is in the enamel. This is because the 
dentine decays more rapidly than the enamel. A cavity 
can be prepared for filling at this stage with little time, pain 
and expense, as shown in Fig. Xo. 2, but if you wait until 
the cavity becomes large, as is shown in No. 3, it requires 
much more time, hurts much worse, costs a great deal more 
and does not last so long. Hence, the teeth should be ex- 
amined several times a year by a dentist, and even 7 de- 
caved spot which is too deep to dress out, filled while it is 



Popular Lectures on Dental Subjects. 73 

small. Tooth decay never gets well, but always gets worse, 
so the sooner the cavity is filled, the better. 

(*) These pictures show the history of a tooth from the 
beginning of decay until the development of an abscess and 
the establishment of a fistula, commonly called a gum boil. 
(Go more or less into the details of the different steps of 
the process and the changes which take place in the pulp, 
giving a few facts pertaining to the proper treatment of 
such cases with special emphasis on the importance of re- 
taining the tooth.) 

If the residue of food is not removed after each meal 
and the last thing eaten something soft and sticky, as is too 
frequently the case, the mouth will sooner or later present 
the appearance of this one with cavities between the teeth 
and in the depressions in the tops of the back teeth, and 
unless dental attention is given this case, the teeth will soon 
be aching and breaking down like the ones in the next slide. 

(*) Some of these teeth have broken so badly that they 
are worthless as grinders, they are liable to ache at any 
time and develop abscesses, they are so many garbage cans 
infesting the saliva which is constantly being swallowed and 
contaminating all food and drink. A mouth in the condi- 
tion of this can not be otherwise than filthy and a great 
menace to the health of its possessor and its neighbors. 

(*) This is a side view of the same case with the teeth 
brought together as in chewing. It shows what an enor- 
mous amount of grinding surface is lost. But even though 
your teeth are as badly broken down as these, you should 
not pull them out. Their tops can be restored by fillings, 
inlays, and crowns, so long as the roots are strong, which 
is immensely better than artificial substitutes. Some grown 
up people may tell you that it makes little difference if you 
lose this first permanent jaw tooth before you are fifteen 
years old, because the space will soon be filled up by the 
next tooth coming forward. Well, the space does fill up. 



74 Practical Oral Hygiene. 

More's the pity. It would be better for you if the space 
didn't close up. Let me show you how the space closes up. 

(*) The teeth behind the space lean forward, and lean 
forward, and lean forward, and the tooth in front of the 
space leans backward and leans backward, until their top 
corners almost or quite touch, thus closing the space at the 
top, but not at the bottom. 

In thus leaning toward each other, their touching surfaces 
are so turned that they fail to touch the upper teeth in chew- 
ing and their fit in is entirely spoiled. The bone buckles 
as the teeth lean, so instead of losing the use merely of the 
tooth extracted, you also lose one-half to two-thirds of the 
grinding efficiency of all the grinding teeth on that side of 
the mouth. But this is only one of the many consequences 
of losing this tooth in early life. It causes a general warp- 
ing of the bones of the nose and front face, which often 
helps to produce catarrh and a number of other diseases 
which we have not time to mention. It is safe to say that 
the loss of this tooth in early life shortens a man's days on 
an average of four or five years. 

If the tooth is so badly decayed that only the roots are 
good, those roots ought to be treated and filled and kept in 
place until one is at least twenty years old. You may do 
anything that your dentist tells you to do except have this 
tooth pulled. If he insists on pulling it, then you should 
tell your mother that you have a poor dentist, and ask her 
to let you go to another. It is very seldom that even a 
temporary tooth should be pulled with forceps, and no per- 
manent teeth, except the wisdom tooth, and seldom that 
should ever be pulled. If you forget everything else in this 
lecture, don't forget what I have said about this first perma- 
nent back tooth. Remember that it is yours at six years 
of age and does not replace a baby tooth, but comes behind 
the last baby back tooth. 

(*) This picture shows how much better a man who has 
not lost this tooth can chew than one who has. One has 
at least one-fourth more grinding efficiency than the other. 



Popular Lectures on Dental Subjects. 75 

(*) When this fellow was a boy, he didn't chew his food 
or brush his teeth, so they soon decayed and ached. He had 
two of his upper teeth pulled. His upper jaw stopped 
growing, but his lower jaw kept on growing, so when he 
got to be a man his teeth didn't fit each other and his jaws 
were not the same size. His chin protruded like this (Il- 
lustration), and he looked like this. 

(*) Do you want to look like that? Well, you had bet- 
ter not have your teeth pulled out. 

(*) This is the kind of dentist who pulls teeth ! If your 
dentist looks like this you had better change your dentist. 

(*) This picture shows how the adenoid tissue in the 
naso-pharynx sometimes becomes enlarged and stops up 
the air passages, so that you can not breathe freely through 
your nose. This makes you more susceptible to nose, throat, 
and lung trouble. It should be removed as soon as discov- 
ered. If you are accustomed to sleep with your mouth open 
and breathe through your mouth while awake, you had bet- 
ter have your physician examine you and see if you have 
adenoids, and if you have, they should be removed. They 
frequently spoil the shape of the mouth and make the teeth 
crooked. 

(*) This is the way the teeth frequently look when one 
has had adenoids. If your teeth are irregular like these, 
you should go to the orthodontist (the dentist who straight- 
ens teeth) and have them straightened. It can be easily 
done while one is young, but if you wait until you are old, 
it is very difficult. 

(*) These pictures show how the face looked before and 
after straightening the teeth. The teeth are much more 
easily and thoroughly cleansed, and are therefore much less 
liable to decay if they are regular and straight and fit each 
other properly. They are also much more efficient grind- 
ers. The first thing for you to do is to see a dentist and 
have him remove all deposits which you can not brush off, 
fill all cavities and put your mouth in perfect order and show 
you how you may keep it so. 



76 Practical Oral Hygiene. 

In making the dental toilet, the first thing to consider is 
the brush. Any kind of brush is better than no brush, but 
the one at the bottom of this picture is too large. Well, it 
is not too large to brush the cow's teeth with, but if you 
don't weigh more than two hundred pounds, it is too large 
for you. If you have a new brush as long as this one, you 
can improve it by shaving the bristles off for about the 
length of the brush. You will then have all the brush that 
you will be able to use. The brush at the top is excellent. 
It has a long tuft of bristles on the end which enable you 
to reach the back sides of the last back tooth. The narrow 
nose, broad base and short body makes it adaptable to the 
various situations and the curve of the handle is an advan- 
tage. Brushes are made in soft, medium and stiff bristles. 
You should use a soft brush. 

The next consideration is a tooth powder. Most all tooth 
powders are made of the same thing — Precipitated Chalk. 
They vary mainly in the perfumes and aromatic and anti- 
septic which they contain. If you get your mouth clean you 
don't need a perfume. Perfume in a dentifrice is a disad- 
vantage, because it deodorizes the mouth and deceives you. 
A pungent aromatic does the same thing and interferes with 
the exquisite sense of touch and taste in the tongue, which 
is the sanitary officer of the mouth, and you may think your 
mouth is clean when it is really only deodorized. If you 
can get your mouth perfectly clean, you do not need an anti- 
septic, whereas, if you fail to cleanse it thoroughly, an anti- 
septic is of slight and transient value. 

Pass the brush as far back in right buccal pouch as pos- 
sible, place high up on the gums above last upper back tooth 
and bring downward with a rotary sweep. 

You will see that as the bristles slide off the gums onto 
the teeth, they separate and sweep out the triangular spaces 
about the necks of the teeth. Now let me ask the girls a 
question: "If you were going to sweep the floor of a street 
car, would you sweep it across the car or down towards the 



Popular Lectures on Dental Subjects. 77 

end of the car? When you are sweeping the teeth to get 
them clean, will you sweep across the teeth or down towards 
the end of the teeth?" You may think that hard, but just 
to show you that it is not, I will brush mine and let you see. 
(Illustrate.) 

Place bristles of brush on cheek side of upper right molar 
gums and sweep downward five strokes. Move forward 
to bicuspid region and repeat. Go back to cheek side of 
lower molar gums and sweep upward five times. Move 
forward to bicuspid region and repeat. 

Place brush high up on tongue side of left upper molar 
gums and sweep downward with a rotary stroke five times 
Move forward to region of bicuspids and repeat. Place 
brush on tongue side of lower molar gums and move up- 
ward five times. Move forward to bicuspids and repeat. 

Take brush in left hand, place brush high up on cheek 
side of upper left molar gums and sweep downward with 
rotary stroke five times. Move forward to bicuspids and 
repeat. Place brush low down on cheek side of lower molar 
gums and sweep upward. Repeat for bicuspids. 

Place brush on tongue side of right upper molar gums 
and rotate downward. Same for bicuspids. Same for 
lower molars and bicuspids. Change brush to right hand. 

Place brush high up on lip side of right upper canine 
gums and sweep downward, working around to left canine. 
Pass to lip side of lower left canine gums and sweep upward 
working around to right canine. 

Place brush high up in roof of mouth and sweep forward 
and downward over right canine. Work around to left 
canine. 

Place brush well under tongue and sweep forward and 
upward over left canine. Work around to right canine. 

Place brush back on grinding surface of right upper 
molars and sweep back and forth to bicuspids. Same on 
left upper molars and bicuspids. 



78 Practical Oral Hygiene. 

Place brush far back on chewing surface of left lower 
molars and sweep back and forth to bicuspids. Same on 
right molars and bicuspids. 

Wash brush and hang up to dry. Rinse mouth vigorous- 
ly with tepid water. Use tooth-pick or dental floss be- 
tween all teeth and behind last teeth. Rinse mouth again. 

The dental toilet should be performed in this way before 
retiring and before breakfast. Immediately after eating 
the mouth should be vigorously rinsed and tooth-pick or 
floss used. If gums are soft or sore they should be vigor- 
ously massaged with the pad of the finger once or twice 
daily. 

If a tooth should be knocked out accidentally, it should be 
washed and replaced immediately and a dentist consulted at 
once. 

In case of illness the mouth should be kept as clean as 
possible both mechanically and by the use of lime water and 
other antiseptics. The tongue should also be frequently 
cleansed and scraped. 

(*) What is the matter with this little fellow? Did you 
ever have toothache? Did you cry? If you will follow 
the instructions given in this lecture you need never have 
toothache again. 

It is not what we learn that makes us wise and happy, it 
is what we remember and practice. 



CHAPTER V. 
POPULAR LECTURES— CONTINUED. 

AN ILLUSTRATED LECTURE BY DR. T. P. HYATT. LECTURE 

FOR SCHOOL CHILDREN BY DR. HUNT. 

LECTURE ON ORAL HYGIENE. 

BY DR. THADDEUS P. HYATT. 

This subject is one that is attracting the attention of the 
whole civilized world. The medical profession and the 
dental profession are discovering to-day that the teeth are 
an intimate part of the whole body — that conditions of the 
mouth affect the welfare and the health of the whole body. 

We are dependent upon three things for our life, and 
without any one of them the body dies, so you will realize 
that these three things must be very important. First, we 
need food; without food the body dies. Second, we need 
water; without water the body dies. Third, we need air; 
without air the body dies. When you remember that these 
three things essential to the life of the body pass through 
the nostrils and the mouth and are affected by the state of 
health of these, you will realize how important it is to con- 
sider the condition of the mouth and the air passages at the 
back of the mouth. It is necessary to have both good food 
and pure water, and they should go into the system without 
any contamination detrimental to that purity. The mouth 
is the portal of the life of the whole body. 

I said the subject was attracting the attention of the whole 
civilized world. In August, 19 13, a convention was held 
at Buffalo, N. Y., of the International School Hygiene As- 



8o 



Practical Oral Hygiene. 



sociation. Governments from all parts of the world sent 
delegates to the convention. The President of the United 
States was the honorary president, and Dr. Eliot presided 
at the convention. The first open meeting of the conven- 
tion was devoted to the subject of mouth hygiene, and it was 
my pleasure to speak at that meeting. When I tell you 
there were over 3,000 persons gathered there, and that this 
session was the most largely attended of all the meetings 
during that week, you will realize the importance of this 
subject. 

The following are some pictures illustrating dentistry as 
performed in the past, and dentistry performed on animals: 




Fig. 21. This picture illustrates dentistry in Persia about 800 
years ago. The poor victim was laid on the ground. Two men 
were necessary to hold him down, and the dentist needed not only 
a pair of forceps, but an iron bar to help him pry out the tooth. 
Of course, in almost every instance the tooth was broken, and the 
patient's condition w T as worse than before. 



Popular Lectures on Dental Subjects. 8i 




Fig. 22. This hippopotamus had an abscessed tooth, and could 
not eat anything, and was in danger of dying. The only way to 
save that animal's life was to extract the tooth and stop the forma- 
tion of more pus. The dentist extracted it. The abscess was 
cleaned out, and the life of that animal was saved. Think of little 
children with abscessed teeth, and consider the difference between 
the strength and the size of a child's tooth and that of a hippopotamus! 







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Fig. 23. This shows a very interesting affair at Luna Park, 
Coney Island. This elephant had an abscessed tooth, and no one 
was strong enough to extract it. A hole was drilled through the 
tooth, and a piece of piano wire passed through it. Then a rope 
was tied to the end of the wire, and tied to another elephant. Both 
elephants were given the signal to back, and out came the tooth. 
That is the first instance known of an elephant drawing a tooth. 



82 



Practical Oral Hygiene. 



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Fig. 24. This is a picture of Jumbo, who was exhibited with 
Barnum's circus, and before that in the Zoological Gardens in Lon- 
don. When I was a boy, in London, I had the pleasure of riding 
on Jumbo's back a great many times, for two cents a ride. Jumbo 
died in Bridgeport some years ago, and he died the death of a hero. 
He saved the life of Alice, his mate. She was standing on the rail- 
road track, and the light from the engine of the train blinded her. 
She could not get out of the way. Jumbo charged the engine, and 
pushed Alice aside, but was himself killed. Jumbo broke both tusks 
when young and abscesses were formed. It became necessary to 
lance the abscesses because pus was being formed, and the life of the 
animal was in danger. The doctor took a hook-shaped lance and 
went into the stall of Jumbo. The doctor got the lance over the 
abscess and ripped it open. In about six months, there was another 
abscess. People make a great fuss if they know they are going 
to be hurt, and expected Jumbo would make a great fuss when they 
attempted to hurt him again. The doctor had his lance ready, and 



Popular Lectures on Dental Subjects. 83 

the keeper was there to use persuasion and force. I do not know 
whether an elephant thinks, or not, but Jumbo must have realized 
that the lancing of the former abscess, which was so painful, re- 
stored him to health, because he came forward to the doctor, lowered 
his head, and turned the left side of his head, keeping perfectly still 
while the doctor opened up that abscess and washed it out and 
dressed it. 

If an elephant can be as intelligent as that, and stand pain, I trust 
each one of you will think of Jumbo, and be as intelligent and brave 
as he was, if it should ever become necessary for you to have any 
dental operation done. 

It would seem almost a preposterous statement to assert 
that the size of the brain depends upon the teeth; and yet 
we are learning to realize that this is absolutely true. A 
physician took six little baby rabbits. He kept one nor- 
mal. On the other five, he mutilated some of the teeth. 
On some, all the teeth on one side were taken out. On the 
others, all the teeth on the other side were taken out. The 
rabbits were allowed to go out and play, and when they 
reached full size, they were killed, and their skulls examined. 
The rabbit that had all its teeth, had a perfectly normal and 
symmetrically developed skull. In the rabbit with its teeth 
cut out on the right side, the skull was not well developed on 
that side, although it was well developed on the left side. In 
the rabbit that had its teeth cut out on the left side, the skull 
had not grown as much nor as symmetrically on the left side 
as on the right side, where the teeth were normal. 

The food is first bitten off by the incisors, then it is 
broken up by the bicuspid teeth, and later it is ground fine 
by the strongest and largest of the teeth, and mixed with 
saliva so it can be swallowed. The first step for digestion 
takes place in the mouth, and if this is not done properly, 
digestion can not be properly done. You can not swallow 
a piece of meat, or bread, or food of any kind, without chew- 
ing it, and expect it to be properly digested. It must be 
properly chewed and mixed with saliva before it is swal- 
lowed. 



8 4 



Practical Oral Hygiene. 




Fig. 25. The crown of the tooth is visible, and the root is not 
visible. Over the crown is a hard substance, known as enamel. It 
is the hardest substance in the whole body, and is pearly-like in ap- 
pearance and lustre when clean. You read in the Bible of the teeth 
as being pearly. They are pearly in appearance when kept well- 
brushed and polished. Covering the root is a substance not quite so 
hard as the enamel, known as the cementum. Inside of this there 
is a substance known as the dentine. Within this is what is called 
the pulp. It is made of soft material and has an arterial supply, 
which gives fresh blood to the tooth. There should be a blue line 
here, to show the venous system, which carries away the blood which 
has become impure. 

If I should say to you that there were eight men taken 
from an insane asylum to a dentist because their teeth needed 
attention, and that six of them did not need to go back again, 
because they became sane after their teeth had been treated, 
you might think I was making a very exaggerated statement. 
Yet that is true. Six of eight men did not need to go back, 
because they became sane. 



Popular Lectures on Dental Subjects. 85 

If I should tell you a blind person was taken to a dentist, 
and when the mouth was put in proper condition, the sight 
returned, you would wonder what the teeth have to do with 
the sight. 

If I should tell you a woman was paralyzed on one side 
of her body, and when her mouth was put in good condi- 
tion, and some old roots taken out, the paralysis disap- 
peared, you might marvel, and wonder what that had to 
do with the teeth, but I will show you. 

Do not think every blind person, or every paralyzed per- 
son, or every insane person could go to the dentist, have 
his or her teeth attended to, and then have health restored, 
or sight returned, or become sane. It happened that the 
trouble in the cases I spoke of was of dental origin. 

Your teeth are more valuable to you than your pocket- 
book. If you go to a dentist and have confidence enough 
in him to let him attempt to save your teeth, you should not 
think of the price he will charge. You should not be afraid 
to put down your pocket-book and tell him to help himself 
to its contents. He may take all you have in money, but 
you can go out and earn more money, but you can not re- 
place lost teeth. They are much more valuable to you than 
your money. If you have confidence in your dentist, you 
will go to him and ask him to examine your mouth, and he 
will tell you, "Here is a small cavity, and if a filling is put 
in now it will last much longer, and protect your tooth much 
better than if you allow it to go on and get larger." 

I had the pleasure of being at a dental meeting and hear- 
ing Dr. Van Cott, one of the most prominent physicians 
of this city, tell of a case of a prominent physician who died 
recently from a case of infection from an abscessed tooth; 
the pus had been carried back to the heart, and a heart lesion 
had occurred, and the physician died from this cause. I 
could not have given you, ten or fifteen years ago, this great 



86 



Practical Oral Hygiene. 



knowledge of the relation of mouth conditions with heart 
troubles. 




Fig. 26. This illustrates a little girl, whose upper teeth projected ; 
the teeth did not come together properly, and she was what is known 
as a mouth breather. Her blood became anaemic. She had en- 
larged tonsils and adenoids, and her health became impaired. She 
did not care about play, or study, or work, or friends. She was 
taken to a dentist, who regulated those teeth so each one would be 
in its proper place, with the result that soon this child was able to 
keep her mouth closed at night. Her appetite became better and 
her health better; she wanted to play, and she wanted friends, and 
she became one of the brightest students in the class. The health 
and the mentality of that child depended on the condition of her 
mouth. 



Popular Lectures on Dental Subjects. 87 




Fig. 27. Here is a young girl whose lower teeth shot out too far. 
Look at her face — the cheeks sunken, her chest is sunken and narrow, 
and she does not look happy. Her mouth was attended to, and see 
the difference in this picture. Look at the good development of her 
chest. Not only was the natural beauty of that child brought forth, 
but health was brought to her, and see how the child responded to 
the physical development! 

Dr. Woods Hutchinson recently said a man in days gone 
by used to fight for his life with his teeth, and to-day we 
find his life depends upon his teeth. Then he said, "A man 
is known by the teeth he keeps." 

I had not realized it until I heard Dr. Hutchinson say 
that, and then I had a slide made to use in my lectures, with 
those words on it. You may not have formulated your 
feeling into words, but you can not look into the face of 
any human being when the lips are parted, and see decayed 
and rotten teeth, without having a feeling of repugnance 
towards that person. You will after to-night formulate 
your feeling, if you have any thought on the subject. If 
you see men or women with good, clean teeth, you will feel 
they are clean, healthy people. 



Practical Oral Hygiene. 



f 




It *» 


4^ 


^B E*' 


m «k- iV 


i w 


^ ^ 


- KP* ^ 


1 <5T^ ^ 


K 









Fig. 28. Here is a young woman with her teeth decayed in front. 
Of what use is it for her to put a pink bow on her hair, or powder 
on the tip of her nose? You feel as though she were not clean. 
There is a feeling of repugnance when she opens her lips and smiles. 
But see when she has her mouth attended to, and the teeth cleaned ! 
There is a feeling of wholesomeness about her, and she does not need 
the pink bow, or the powder on her nose to make her attractive. 

It was my good fortune to go to Bridgeport not long 
ago and see the tooth brush drill there. You would be sur- 
prised to see how eager and happy the children are to learn 
it. The children are instructed to take their tooth brushes 
home, and how to use them, and they take such an interest 
in them, and consider them of so much importance, that re- 
cently, in one of the homes, it was found that the child's 
tooth brush was kept on the parlor mantel-piece ! 

It is significant to find, too, that a little burglar broke 
into the dental assistant's office, where the supplies were 
kept, and stole twenty tooth brushes, and gave them to his 
little friends. When children will begin to burglarize to 
get tooth brushes for themselves and their friends, it looks 
as though the importance of having clean teeth was begin- 
ning to be appreciated. 



Popular Lectures on Dental Subjects. 89 




nv 



Fig. 29. Here is a picture showing that McGraw, who has charge 
of one of the great baseball teams has learned that as a business 
proposition, it was not only advisable but exceedingly desirable to 
have a dentist take charge of the teeth of the players. They could 
not play well if they were suffering from their teeth. 

The Japanese army, in their war with Russia, had wagon- 
loads of tooth brushes and tooth powder with them, so that 
the Japanese soldiers could keep their teeth clean, and their 
mouths in good condition, knowing the effect that bad teeth 
would have on their general health. 

The manager of a large St. Louis concern sent one of his 
best salesmen out to get an order of $50,000, and he real- 
ized that the order was lost because the salesman w r hen ar- 
riving at his destination had an abscessed tooth, which was 
so painful that he was not able to do any business. He had 
to go to the dentist and get relief, and he was so weakened 
and distressed that he could not attend to his business, and 
someone else got the order. 

That manager said: "No salesman will go out from here 
any more unless his teeth are in good condition." 



90 Practical Oral Hygiene. 

The government is spending large amounts of money that 
your food supply shall be pure; but what about the mouths 
into which this pure food and this pure water go? 

Many persons have made the remark: "If you are going 
to teach people to keep their teeth clean, and not let them 
decay, you will deprive the dentist of work." It is very 
difficult to keep teeth perfectly clean; but there is not a den- 
tist in this city who would not prefer to work in a clean 
mouth, knowing that his work will be appreciated if a person 
realizes the importance of the cleanliness of the mouth. 

There is nothing I feel quite so badly about, as after 
having done a nice piece of work — and there is pleasure in 
doing nice work — to find that the person is so careless as 
to allow the mouth to become filthy, so that decay takes 
place, and my work will be destroyed. It does not satisfy 
me to know that I have completed the work; I would like 
to know that the work is being kept clean, and that it will 
last. 

Supposing, for example, a law were passed that every 
man, woman and child in New York City should have their 
teeth taken care of, and their mouths put in perfect condi- 
tion. Suppose every dentist in the United States, in all the 
large cities, and in all the villages and country towns, were 
brought to New York City; then suppose we compelled 
these men to work ten hours a day — Sundays as well, and 
holidays — they would work 365 days a year, ten hours a 
day. How soon could they fill all the cavities in the teeth 
of the people of New York, and put their mouths in good 
condition? It would be three, four or five years before 
we could do the work that is necessary, in New York City 
alone to-day; and think of the new cavities being created 
in those three, four or five years. This task is beyond the 
power of man. 

The only way to cope with the people, is to come before 
the people and try to explain to them the importance of their 



Popular Lectures on Dental Subjects. 91 

mouth and teeth, and the intimate relation between the 
mouth and teeth and the different parts of the body, and 
get the people aroused to the point that they are willing to 
keep their mouths as clean as possible, and teach the chil- 
dren in the schools, so they can have the tooth brush drill 
and all the things that help to keep the teeth clean. 

In Boston, at St. Vincent's orphan asylum, where 300 to 
400 children are kept, they engaged a dentist. In that in- 
stitution they used to have an average of 108 cases of chil- 
dren's diseases during the year. Dr. Keyes and several 
assistants came there and instructed the children in the tooth 
brush drill, examined the children's mouths, extracted those 
teeth that could not be saved, filled the others so they could 
be used for mastication. 

At the end of the first year, they had only sixty cases of 
sickness; at the end of the second year, none; at the end of 
the third year, none; and at the end of the fourth year, four 
cases of measles that were brought in by a new child. 

The prevention of sickness in this orphan asylum that I 
mentioned, came from the fact that the children kept their 
teeth and mouths clean, and prevented infection from get- 
ting into their bodies. 

I sometimes ask a patient, "Do you rinse your mouth?" 
They say, "Oh, yes." I say, "Rinse your mouth." They 
take a mouth full of water — so full that they can not move 
it around, and then spit it out. That is of no use at all. 
I sometimes tell my young patients to spit between their 
teeth, and keep the lips together. Then you force the 
liquid between the teeth, carrying the food with it. 

I am sometimes asked, "How often shall I clean my 
teeth." One lady asked me this recently. I looked at her, 
and felt sure she cooked her own food, so I asked her how 
often she cleaned her pots and pans and cooking utensils. 
"Why," said she, "as often as I use them." Then I said, 
"That is how often you should clean your teeth." 



92 Practical Oral Hygiene. 

Microbes find their most speedy development in the 
mouth. There is no apparatus made for the development 
of microbes when we want to study them that is as good 
an incubator as the human mouth. I heard a physician — 
not a dentist — advocate the cleansing of the mouth before 
meals as well as after meals. That is asking a great deal, 
but do it as often as you can. If you can only do it once 
a day, do it at night. 

To my audience of ohildren I often put this question: 
"How many children go to bed with their shoes on?" No 
hands are held up. I tell them they would not be doing as 
much harm to themselves if they kept on their shoes, as they 
will if they go to bed with food on their teeth. I ask them 
to promise not to take off their shoes until their teeth are 
cleaned. 

Broken down bone tissue is more poisonous and irritat- 
ing to the mucous membrane of the digestive apparatus 
than the discharge of an ulcer on the arm. You would not 
put your lips to an ulcer and swallow the poison from it; 
yet you are swallowing the poison from your broken down 
teeth all the time. If you would realize that you would 
go to your dentist in a better frame of mind, and you would 
co-operate with him. 

If I have made this lecture interesting, and have been 
able to impress its importance upon you, I hope you will 
tell your friends about it. I hope you will tell them to 
watch the little child who has its sixth year molar coming 
into the mouth; and if you impress the importance of this 
upon them, so that they will take care of their teeth, I shall 
be repaid for my lecture. 



Popular Lectures on Dental Subjects. 93 

LECTURE FOR SCHOOL CHILDREN WRITTEN ESPE- 
CIALLY FOR THIS BOOK BY THE LATE DR. 
GEORGE EDWIN HUNT. 

Now, young ladies and gentlemen, I am here to-day to 
give you a talk about the mouth and teeth, and since it is 
easier to ask questions than to answer them, I am going 
to begin by asking you a question or two. The reason why 
your teachers ask you so many questions is because it is 
easier to ask them than to answer them. The first question 
I am going to ask is, "How many of you washed your faces 
before you came to school this morning? Hands up." 
Well, that's good. I guess everybody washed their faces 
before they came to school this morning. There's one boy 
over there in the corner that only put his hand up part way, 
but I guess he must have washed for a high-necked collar. 
Now, I'm going to ask another question, "How many of 
you cleaned your mouths before you came to school this 
morning?" Ah! that's not quite so good. Quite a num- 
ber of you did, but there's quite a number of you that did 
not. Now, in my opinion, if you are going to make a choice 
between these two things, I think you should clean your 
mouths and not wash your faces, but if I were you I would 
do both, because if you don't wash your faces you won't 
look very pretty, and if you don't clean your mouths, a lot 
of other things are going to happen to you that I'll tell you 
about. 

Now for another question: "How many of you ever had 
toothache?" My goodness! Nearly every one of you has 
had the toothache. And those of you that haven't had 
toothache certainly have seen people having toothache and 
know what it is like. Suppose I tell you what makes your 
teeth ache. In order to do it, I am going to ask you another 
question. I am a great fellow for asking questions. "Sup- 
pose the evening meal was over and everybody had left 
the dining-room but mother, and mother is clearing up 
the table. She finds some nice boiled potatoes, and 



94 Practical Oral Hygiene. 

here is a nice piece of meat too large to be thrown away, 
and here are some other vegetables that she can keep until 
to-morrow. Maybe she will chop up that meat and put 
potatoes with it and have hash for breakfast. When 
mother makes hash it is a pretty good thing to eat. Now, 
where does mother put that food to keep it until to-morrow, 
so that it will be nice and fresh?" (A pupil — "In the ice 
box.") Yes, she puts it in the ice box. But why does she 
put it in the ice box? Why not just put it out on the back 
steps where the sun will shine on it and the rain will fall on 
it? Now, we won't say anything about the dog or the cat 
getting it or the birds carrying it away, but just tell me what 
happens to food if she were to do that? (A pupil — "It 
w T ould rot or decay.") That's it. It would rot or decay. 
Well, that's just exactly what happens to food in your mouth. 
That isn't very pleasant to think about, is it? Every time 
you eat, you leave some particles of the food, no matter 
what kind of food it is, about the necks of the teeth and in 
between the teeth, and if it isn't removed that food rots or 
decays just as the food from the dinner table would do if 
mother put it out in the sun and rain. Now, when that food 
rots in the mouth there are certain acids formed, so you are 
carrying around a sort of acid factory in your mouth and 
nobody wants to feel that they are an acid factory. This 
acid dissolves the tooth just as water will dissolve sugar 
when you pour the sugar in the water and stir it up, al- 
though it does not dissolve it nearly so fast. But it dis- 
solves it just a little at a time and the first thing you know 
that tooth has a cavity in it. A little later on that cavity 
gets deeper and pretty soon the tooth begins to ache. And 
that's the way you have decayed teeth and have toothache. 
Don't you think it would be better not to leave those par- 
ticles of food around the teeth so that they will form acid 
and give you toothache? 

There are three reasons why I think you ought to take 
care of your teeth. The first reason is that you will not 



Popular Lectures on Dental Subjects. 95 

have pain. The second reason is that your health may be 
better. The third reason is that you may be more beauti- 
ful. Now, when I talk about being more beautiful, these 
boys laugh in their sleeves because they think they don't 
care whether they are beautiful or not, but we girls know 
that in a few years from now we will wish we were good 
looking, don't we? 

Now, in regard to the first of these three reasons. You 
have told me that nearly all of you have had toothache and 
that those who have not had toothache have seen people 
who were having toothache, so that I don't think it is neces- 
sary to spend any time in telling you that toothache is not 
a good thing to have. Nobody would go around hunting 
for a toothache. So we will just take it for granted that 
you know that you don't want a toothache and think that 
your teeth should be cared for on that account. 

Now for the question of health. You have all heard of 
a certain part of the body which has an awfully long name, 
and which it is difficult for me to remember, but I can some- 
times recall it — the alimentary canal. It is in this alimen- 
tary canal where all digestion of food takes place, and if it 
wasn't for the alimentary canal, we would all starve to 
death. I don't know whether you know it or not, but the 
alimentary canal in grown-ups is over thirty feet long. That 
would make a person awfully tall if the alimentary canal 
was straight, but it isn't straight. Now, here's the point I 
want to make. In that whole thirty odd feet of the alimen- 
tary canal there are only three inches — these three inches 
from the teeth to the back of the mouth — over which you 
have control of your food. Now, since digestion starts here 
in the mouth and digestion can not start properly unless this 
food is well chewed, and since you have no control over the 
food after you swallow it, don't you think it's a good plan to 
take care of it while you have a chance to do so? 

Now I'm going to tell you how to eat. I expect you think 
you know how to eat but I don't believe you do, and I'm 



96 Practical Oral Hygiene. 

going to ask you to do something for me. When you go 
to the supper table this evening, I want you to take a bite 
of bread and butter out of the middle of the slice. Don't 
get any of the crust, but just get the soft inside of the slice. 
Then see how long you can chew that. Now you probably 
think you can chew it just as long as you please but you can't. 
After a while, and it won't be very long either, you will find 
that there is nothing in your mouth. You have swallowed 
that bread and butter and didn't know when you did it. 
That's the way you ought to chew most foods. You can 
chew potatoes that way and most cooked vegetables, but not 
all of them. Then there are some foods you can't chew 
that way at all, so they will swallow themselves. Unless 
you get better beefsteak here than we do where I live, you 
can't chew beefsteak that way, and unless you get better 
celery here than I do, you can't chew celery that way, be- 
cause it is stringy, and you can't always chew string beans 
that way unless they are very well unstrung. However, 
those foods that you can't chew until they swallow them- 
selves, should be chewed until there is no longer any taste 
to them. Then you can swallow them all right. Now if 
you would chew your foods that way, it would be a great 
thing for your teeth and gums, and I am sure you would 
enjoy it more if you would once get in the habit of eating in 
that manner and your health would be very much better. 

Now, girls, I am going to talk to the boys a few minutes 
and you can listen if you want to. How many of you boys 
ever heard of a game called baseball? Well, I guess most 
of you know all about baseball. Well, if you boys want to 
be good baseball players, or good football players, or good 
tennis players, or good in any other line of athletics, you 
have to have good teeth, and you have to use them properly. 
Now maybe you think that is a funny thing for me to say. 
But don't you see, that since digestion starts in the mouth, 
that if you don't have good teeth to chew your food with 
and don't use your teeth properly you won't have good di- 



Popular Lectures on Dental Subjects. 97 

gestion. Nobody with poor digestion can ever be a good 
athlete. Did any of you boys ever hear of Connie Mack, 
or John McGraw? Why of course you have. Connie Mack 
is manager of the Philadelphia Athletics, the champion base- 
ball team of the world, and John McGraw is manager of 
the New York Giants, which is the second best team in the 
world. Well, when the Athletics and Giants report early 
in the spring for spring practice and to go to the training 
ground, Connie Mack and John McGraw make them go 
to the dentist and have their mouths put in order before 
they can ever begin training. Now, Connie Mack and 
Johnnie McGraw don't care whether those ball players of 
theirs are pretty or not, nor they don't care particularly 
whether those ball players have pain or not, but they do 
know that if the ball players mouths are not in good condi- 
tion that they can't play ball as well as they could if their 
mouths were in good condition. Suppose there was a World 
Series on and the Athletics had won three games and the 
Giants had won three games and the next game was to de- 
cide the world's championship. And suppose the next morn- 
ing Baker, of the Athletics, their best batter, were to show 
up at the ball ground with his face swollen out with an ab- 
scessed tooth. He couldn't play baseball that day. Even 
if he tried he couldn't play well. And his absence from the 
team might cause the Athletics to lose the world's champion- 
ship. So you see that to athletes, bad teeth are a great 
handicap. Connie Mack knows that and that's why he in- 
sists that Baker's teeth shall be in good condition and that 
he shall keep them in good condition all through the playing 
season. He knows that Baker wouldn't play as good base- 
ball if he had a mouth full of bad teeth. 

And now you girls. You like your roller skates, and you 
like to play tennis, and you like to dance, and you like to do 
a lot of other things that depend a great deal upon the con- 
dition of your health. Then you don't want to have indi- 



98 Practical Oral Hygiene. 

gestion and headaches and all those kind of troubles when 
you are growing up because they interfere with your school 
work just as they interfere with the boys' school work also. 
And unless your teeth are in good shape and you use your 
mouth properly, you will not be in good health. Nobody in 
school can do their best work and keep up with their studies 
if they are suffering with toothache, or if they are suffering 
from indigestion, because of the condition of their mouths. 
You don't want to fall behind in your classes and have to 
take a part of the work over again, and yet you can't keep 
up with your classes unless your health is good and your 
health can't be good unless your mouth is in good condition. 
So you see your health depends a good deal upon the condi- 
tion of your mouth. 

Now to take up the third reason why you should care for 
your mouths. You boys may not think now that it makes 
any difference whether your mouths look good or not, but 
it does. Pretty soon now, you boys will have to get out in 
the world and earn your own living. Your fathers and 
mothers have been pretty good to you so far, but they can't 
take care of you always, and after a while you have to earn 
money for yourselves. Then again, later on, perhaps, you 
will have to be earning money to take care of one of these 
girls, also. Now, suppose a wholesale merchant in this town 
wanted a boy to come into his establishment and start way 
down at the foot of the ladder, with a prospect of working 
up. It may be the boy could get to be a general manager 
of the institution after a number of years, or head book- 
keeper or some good paying job. Suppose two boys apply 
for this job. One of them has a mouth full of dirty teeth, 
with green scum on them, cavities showing in the front teeth, 
mouth foul as can be, breath bad on account of his decayed 
teeth, perhaps one or two teeth gone. The other boy has a 
mouth that shows that he has taken care of his teeth, that he 
cleans his mouth, and takes some pride in it. Which one of 



Popular Lectures on Dental Subjects. 99 

those two boys will the merchant hire, other things being 
equal? He'll hire the boy with the clean mouth. He will say 
to himself, "This boy with the clean mouth takes some pride 
in his appearance and is more likely to take pride in his 
work. This boy with the dirty mouth is very likely to be 
slovenly about his work." And then again, the merchant 
would argue to himself, the boy with the bad mouth is more 
likely to lose time and neglect his work on account of tooth- 
ache than the boy with the good mouth. So you see that it 
does pay you to have good looking mouths, even in business, 
and it pays you girls, too. Of course, you are more likely 
to have pride in your looks than the boys are, but from a 
purely business standpoint you ought to take care of your 
teeth. If you grow up and have to earn your own livings 
or want to make a little extra money working in an office 
or store, you will find that you can get work a good deal 
quicker if you have nice looking mouths and nice looking 
teeth, than you can without them. Merchants don't like to 
hire a girl in their store to sell goods to customers if her 
mouth is in such shape that her breath is bad and her 
appearance is bad. Everybody ought to be as handsome as 
they can in this world, because other people have to look at 
them and they ought to make it as easy for the other people 
to look at them as they can. So those are the three reasons 
why I think you ought to take care of your mouth and teeth, 
and now having told you all of this about what will happen 
to you if you don't take care of them, I think I ought to 
tell you how to take care of them. 

But, first let me tell you how often you ought to clean your 
mouth. Of course, if you could do it, it would be better 
for you to clean your mouths every time you eat anything, 
but that isn't always possible. I think, if I were you, I would 
rinse my mouth out with water the first thing when I get up 
in the morning. Then after breakfast, I would use my tooth- 
brush and the floss silk in the way that I will describe to 



ioo Practical Oral Hygiene. 

you, and then if you don't clean them again until just before 
you go to bed, you will haye done pretty well, anyhow. 
Always give your mouth a good cleaning just before going 
to bed. Don't forget that, because it is very important. 

(Now the lecturer should give a talk on the toilet of the 
mouth. If stereopticon views could be shown t they can be 
begun at any point in the talk that the lecturer desires. 
Personally, I begin showing my stereopticon views as soon 
as I have wound up my argument for good teeth. That is, 
just before this talk starts in on telling them how to take 
care of their mouths.) 



CHAPTER VI. 

DENTAL EXAMINATION AND CLINIC FOR 
PUBLIC SCHOOLS. 

HISTORY. SCHOOL INSPECTION. HOW TO START SCHOOL 

INSPECTION. REASONS FOR FREE DENTAL CLINIC AND 

SCHOOL INSPECTION. — IMPORTANCE OF DENTAL 
INSPECTION, BY DR. ZARBAUGH 

HISTORY. 

It is of interest to note that in 1879 Russia started this 
inspection. Chicago, some thirty years ago, was the first 
city in the United States to have this work. Ann Arbor, 
Mich., was one of the first cities to make this inspection 
under the supervision of the school board. Cambridge, in 
1907, had the first school dental clinic operated in this coun- 
try. Nearly all the foreign countries have made great 
strides in this direction, and America has, at last, awakened 
to the need of this work. Nearly every state in the Union 
is now doing some work along this line. 

SCHOOL INSPECTION. 

The object of education in its broadest sense is to make 
of the children efficient citizens. This is proving a very 
costly proposition in regard to taxes. The erection of new 
buildings and the increasing of teachers' salaries are not the 
only reasons for this cost. Probably, one of the most impor- 
tant problems is the thousands of dollars expended each year 
for the education of children who will never reach the age 
of citizenship. Now, the main point is that most of these 
deaths are from preventable diseases, and the further point 



102 Practical Oral Hygiene. 

is, that most of these preventable deaths could be prevented 
by proper dental attention. The proof of this case can 
easily be established by the study of the statistics of any well 
directed dental clinic. Here is the only investment where the 
Board of Education can realize ioo per cent, for every 
dollar spent. 

The State recognizes that education is the best thing to 
give a child in order that the future citizens may be more 
efficient. Thus, free education is offered, but we have found 
that many defects in these children, such as bad teeth, will 
not only prevent them from taking full advantage of this 
state service, but that the future citizen is injured for life. 
When the state begins to realize that most of these defects 
can be easily corrected or entirely prevented, then, the uni- 
versal adoption of inspection and the dental clinic will be 
a fact, — necessary as a school desk. 

One of the speakers at the dedication of the Forsyth 
Dental Infirmary was Dr. Donald M. Gallie, President of 
the National Dental Association for 191 5. In his address 
he said: 

"It was not until epidemics broke out in schools through- 
out the country and the carrier of contagion was traced to 
the mouth, teeth and tonsils, that the people and our medical 
teachers realized the importance of our campaign. In ad- 
dition, a scientific and practical test was made in the Marion 
School of Cleveland, which demonstrated conclusively that 
the mental, moral and physical condition of school children 
was greatly improved by dental inspection, instruction and 
care. 

"In 191 1, when preparing the annual message for the 
Illinois State Dental Society, I wrote to the President of 
the School Board and the Commissioner of Health of every 
city in the United States and Canada of over 35,000, of 
which there are about 130, asking them the following ques- 
tions: 



Dental Inspection in Schools. 103 

"1. Are the children of the public and parochial schools 
of your city instructed in the care of the teeth and surround- 
ing tissues? 

"2. Are the teeth of these children examined by a den- 
tist? 

"3. Have you any free dental clinic in your city where 
the teeth of the poor are cared for? 

"I received sixty-five answers. 

"To question 1 — No, 40; yes, 25. 

"To question 2 — No, 52; yes, 13. 

"To question 3 — No, 42; yes, 23. 

"In answer to question 3, the twenty-three answering yes 
were practically all from cities having dental colleges. To- 
day, but three years later, if we were to send out this inquiry 
we would find that not only in practically all the large cities, 
but also in scores of the much smaller cities or towns they 
have inaugurated dental inspection, class instruction, and in 
many cases some means of caring for the unfortunate. In 
many of the large cities provision has been made for from 
five to fifteen clinics, and appropriations for this purpose run 
as high as $20,000 yearly. Surely this is making progress, 
and gratifying as it is, yet how inadequate when we consider 
the tremendous demand and need! 

The State of New York was the first to establish and give 
official recognition to Oral Hygiene in connection with the 
Department of Health. This Oral Hygiene department was 
inaugurated February 19 13. Cities and towns are visited 
by official lecturers who are furnished with the most efficient 
charts and lantern slides. 

Dr. W. A. White was one of the first to give lectures for 
this department of the work. He writes: 

"The failures in final examinations in our schools show 
that 50 per cent, is due to trouble with the mouth and teeth. 
These delinquents, classified as repeaters, have awakened 
the Boards of Education and brought to their attention an 



104 Practical Oral Hygiene. 

important duty to such an extent, that a thorough investiga- 
tion of the cause of this large percentage of failures, has 
been carried on, which proved to be "decayed teeth," and the 
result has been that free dental dispensaries, in connection 
with the schools, have been established in all sections of the 
state, and nearly every school building now under instruc- 
tion will be provided with a complete dental equipment, for 
the benefit of the poor boys and girls attending these re- 
spective schools, who may need dental attention, which will 
have a tendency to obliterate much of this long neglected 
condition, and will, as has been satisfactorily demonstrated, 
be the logical medium for moral, mental and physical im- 
provement as well as normal development, and will demon- 
strate to the world that scientific research work has done no 
greater work than to acquaint mankind with the relation that 
the mouth and teeth bear to the human body and health 
which very clearly show us that every phase of the dental art 
is a dominating factor in dealing with the health problem 
in all of life's characteristics." 

Dental examination in public schools consists of inspect- 
ing and tabulating the oral conditions of the students by some 
dentist under authority of the local dental society or public 
school authority. 

The object to be gained by the inspection of the teeth of 
school children is : 

First, to show the people and the parents the actual exist- 
ing conditions. To tell, for instance, that in New York 
examinations show such and such defects, is not as interest- 
ing as to show them the conditions in their own children's 
mouths. 

Second, to increase the working capacity of the child. 

Third, to accumulate data which will in the future force 
the people to wake up on this subject. 

Fourth, to show, by comparison with schools that have 
established this system, what can be done. 



Dental Inspection in Schools. 105 

All statistics of school examinations show that dental 
lesions are in the majority of all defects, ranging from 80 
to 98 per cent. 

One of the objections that will arise in the minds of the 
school board, whether expressed or not, will be that they 
invariably think that the dentists have some ulterior motive, 
or that they are ambitious to advance themselves. This, of 
course, can be met with the fact that the dentist, in many in- 
stances, is doing the work free of charge, and, in addition, 
is furnishing material, charts, and stationery at his own 
expense. Medical examiners are generally paid a salary or 
else a fee for some special examinations. 

HOW TO START DENTAL SCHOOL INSPECTION. 

As nearly all schools have some sort of medical examina- 
tion or supervision, the beginning of dental attention must, 
of necessity, be done through the medical examiner. It is 
a good start for the dentist of local society to secure the 
medical examiner's sympathy and co-operation. Have him 
visit some dental office and show him by pictures and by ex- 
amination of a patient what to look for and how to find de- 
fects in children's mouths. Mail him reprints from the 
dental journals on the subject. 

In attempting to start dental inspection or clinics in a new 
place, the dentist often finds a lack of interest or even oppo- 
sition on the part of the commissioners of education and the 
teachers. This is humiliating. On the other hand, we have 
found that physicians do not have to beg the schools to ac- 
cept their services, but are welcomed, and the necessary 
funds are forthcoming for their enterprise. It is even 
necessary sometimes for dentists to beg to put in dental in- 
spection in one school just to show these men from "Mis- 
souri" what can be done. This is the one place where it is 
better to work first with the medical examiner. Go to him, 
teach him how to examine for dental defects, and then get 



106 Practical Oral Hygiene. 

him to state in his reports the dental defects which he has 
found. This will do the authorities more good than forty 
dentists going before them. After the medical examiner has 
done this, you have the entering wedge. 

When the medical examiner has made his report, the next 
man to see is the superintendent of the schools. Put the 
facts up to him as given in our chapter on Oral Hygiene. 
Explain to him that it is not placing a burden on his pupils, 
but taking a burden off of them. If you can win his co- 
operation, one-half of the battle is won. Taking him along 
with you to see the president of the board of education, and 
at a special meeting have a committee along with reliable 
facts on oral sepsis, and show literature and statistics from 
other schools which have inaugurated this system. Show 
them how pupils with dental irritation are unfit for study. 
Offer to make a voluntary inspection of one school at the 
opening of the term and at the close of the term. Have 
prepared blanks somewhat on the order of those shown in 
this book, and then the next year when it goes before the 
board of education, meet them on a plain business basis. 
After you have secured consent for the first examination, 
see that the parents are acquainted with the conditions of 
the children's mouths, and that the child is interested through 
popular lectures in prophylaxis, tooth brushes, and denti- 
frice. It is also well to have some slides with pointed para- 
graphs on them or printed cards. Stop in the lecture and 
write these points on the black-board every few minutes. 
A break in a lecture like this has a good impression. State- 
ments like the following should be used: 

"A Clean Mouth Prevents Pain and Illness." 

"Food Left Between Teeth Causes Decay." 

"Dirty Mouths Breed Disease Germs." 

"A Clean Tooth Never Decays." 

"Clean Your Teeth After Eating." 



Dental Inspection in Schools. 107 

Sometimes it is necessary to use some other attractive 
schemes to produce results. In Wilksburg, Pa., the dental 
society devised a plan by which the children were induced to 
use the tooth brush and dentifrice furnished by the society. 
With each package, a check was given to the children. Five 
of these checks would secure a package free. The checks 
were given out by the teachers for keeping the teeth clean 
and owning a tooth brush. The reports from the use of such 
schemes seem to indicate that they are proving their worth; 
the statistics collected by the dental examiners have been 
highly satisfactory, and the parents of the children have 
shown a keen interest in the work. 

• Out in Oklahoma they use some original ideas in regard 
to teaching oral hygiene and have made quite a success. 
Dr. L. G. Mitchell describes this method and system as fol- 
lows: 

"At the invitation of our State Board of Health we pre- 
pared an oral hygiene exhibit that was sufficiently complete 
to furnish subject matter for a complete lecture. This ex- 
hibit has been taken to a number of towns and cities in the 
state where suitable lectures were given by local dentists. 
This was brought to the State fair, where lectures were 
given each afternoon by local men, suitable literature being 
given to those interested. 

u At our 'Better Babies Contest' during the fair, it was 
noticed that there were fewer discolored teeth than a year 
ago. 

"Our State University, taking cognizance of the impor- 
tance of the work, has purchased a stereopticon lantern for 
our use. 

"There seems to be a widespread opinion that the exami- 
nation of the mouths of school children, sending to the par- 
ents a chart showing what work is needed, is a very impor- 
tant initial step in this work. While I agree that this is 
important and productive of much good, still I am convinced 



io8 Practical Oral Hygiene. 

that the same amount of time and energy could be better ex- 
pended in delivering suitable lectures to the school children. 
Simply the examination of the mouth, telling the children 
that needed work should be done, the children in turn re- 
peating this to the parents, and showing the chart, does not 
bring the definite and actual results as do the lectures. 

"It is not difficult to impress the children with the WHY 
in lectures, and when this is done you are going to get quicker 
action. The children will carry the message home just the 
same as though their teeth had been examined and they will 
begin using the tooth brush, which is the principal thing we 
are after. 

"While the correction of faulty conditions is important, 
it is of greater importance that we emphasize prevention, 
so if it is not feasible to construct an elaborate machine for 
making these examinations, carefully charting the results 
and conducting the lectures too, I believe it is best to confine 
the work to the lectures. 

"Again, to go into a school and make examinations dis- 
turbs the class work. This is also true in delivering lec- 
tures. All this means a heavy draft on the patience and 
forbearance, or let us say patriotism, of the teachers and 
school board. 

"In our lecture work here we adopted this plan: We 
arranged with the principal to lecture at an hour that best 
suited the convenience of the teachers. They put two and 
sometimes three rooms together. In introducing the speaker 
his name would be omitted, thus giving the speaker an op- 
portunity to disarm the children and the parents of the very 
prevalent belief that we were doing this simply to increase 
our business. The same plan is being followed when ad- 
dressing school patrons' clubs. 

"The State School Board issues a book which is an out- 
line of all subjects to be taught and the manner in which 
they shall be taught. This is called the 'Course of Study' 



Dental Inspection" in Schools. 109 

book. This is the official guide for all teachers of the State, 
except in cities of the first class. The State Superintend- 
ent permitted us to prepare several pages of instructions 
to teachers for this book. The same matter was published 
in pamphlet form to be placed in the hands of the teachers 
in cities of the first class, so that every teacher in the State 
has this matter as part of their official instructions. (Any 
one desiring a copy of this will receive one upon applica- 
tion.)" 

A simple and efficient method of teaching children the 
importance of oral hygiene was carried through to a success- 
ful issue by the Superintendent of the Watouga, Okla., City 
Schools. First, the teachers received several lectures on the 
subject from a competent dentist. Superintendent Gaddy, 
in writing of his method, says: 

"I called a formal meeting of the school board, the drug- 
gists, the physicians and the dentists to which meeting I 
briefly but fully outlined a plan which they considered feas- 
ible and which was unanimously adopted. The plan submit- 
ted called for the following which all agreed to. The 
druggists to furnish a tooth brush and tube of paste for 
twenty-five cents, provided the same were to be used in the 
'tooth brush drill.' The dentists agreed to treat the teeth 
of any child free of charge provided their parents were fi- 
nancially unable to pay for same. The physicians agreed 
to treat all throat troubles in the same manner. 

"The school carpenter was instructed to construct a cov- 
ered box for each room, each box having sixty holes in the 
lid the name of each child being placed immediately under 
the holes. Every morning the children w r ould file past this 
box to take their brush and with their individual cups file out 
into the yard, their teachers standing before them with a 
brush and cup of water superintending and leading the 
'tooth brush drill.' The children then file back, replace 
their brushes in the box in their proper places, handles first. 



no Practical Oral Hygiene. 

They are then allowed to dry in the sun. These boxes are 
then placed in a large cabinet made expressly for them. The 
cabinet is tightly closed and brushes fumigated with a dis- 
infectant which kills all germ life which has escaped the 
sunlight. The large cabinet is 62m. by 2oin. x 33m. deep, 
and holds 12 class room boxes. 

"It is too early at this time to note any decisive good in 
the case of diphtheria which broke out in one room. Not 
one of the pupils who were exposed contracted the dis- 
ease and contrary to custom we did not dismiss a single room 
but held closely and vigorously to the 'tooth brush drill.' 

"The Watonga school system is not over supplied with 
teachers, yet not one of the corps has complained of over 
work on account of this oral hygiene work. On the contrary 
every one grows daily more anxious and enthusiastic about 
the good it is working for the children. None of the reg- 
ular branches are in any way neglected, yet I dare say that 
it is of vastly more importance than some of the branches 
now incorporated in our school system." 

Before the beginning of the school inspection, it is well 
to have printed the proper charts, the best of which are 
shown in this book in the following pages. Several adjust- 
able head rests attached to common chairs, can be used for 
the examination. The examination should be made in a 
room separate from the class room, and three or four stu- 
dents called out togther. It is well to have a trained nurse 
to attend to the sterilization of the instruments. The as- 
sistance of several young dentists, who will generally be glad 
to give their services, should be arranged. The cards should 
be given to the children before they reach the examining 
room, with name and grade filled in. Since we do not have 
to include in our report all the minor defects which are 
found, the examination of about fifty children an hour can 
be counted on as an average. Specific information should 
not be given on the card which is sent to the child's parents, 



Dental Inspection in Schools. hi 

as the reputation of the family dentist must be protected for 
the good of all. The only object of the examination being 
to let the parents know that they should have either their 
family dentist, or the school clinician to make further or 
more extensive examination of the teeth. 

After the examination is complete, the popular lectures 
should be begun and the children and their parents invited. 
At these lectures the statistics of the examination should be 
shown, and means of improvement emphasized. All the 
while the first point in this movement is to remove the child's 
apathy towards the dentist, and to urge the necessity for 
oral hygiene measures. Get the child so interested that he 
will insist on the repair of the defects. 

In all Oral Hygiene we must bear in mind the physiolog- 
ical laws by which the mouth and teeth are governed. It is 
of no use to lecture on clinics and things of this nature 
unless the child or the parent knows something about the 
diseases of the teeth and how to prevent them. This must 
first be understood in order that you may suggest to them 
the proper remedy for the cure. Thus, the mere filling of 
teeth at a dental clinic does not always accomplish good re- 
sults unless we teach the child in simple language the dan- 
gers of destruction of the teeth and how such diseases can 
be prevented. In other words, it is the duty of those inter- 
ested in this work to prove that healthy mouths are neces- 
sary for healthy bodies, and that healthy mouths may be 
accomplished by the means above described. We, as den- 
tists, are apt to forget how little people know about teeth 
and how to care for them. 

The dental colleges should be specially instructed to help 
in this work. In those places where there is no dental col- 
lege, and where there is not time to establish a dental clinic, 
the practitioners must give certain hours to this free work 
for those who can not pay for it, for, the failure to repair 



I I 2 



Practical Oral Hygiene. 



these defects found in the teeth of the children, would result 
in upsetting all the plans for prophylaxis work in the future. 

REASONS FOR FREE DENTAL CLINIC AND SCHOOL 
INSPECTION. 

It saves money for the county and state, for much of the 
expense of teaching goes to laggards, and a large per cent, 
of the laggards are made so by some physical defect. The 
largest number of physical defects lies in the teeth. This 
corrected, the laggards become normal in their class rooms. 
By putting the laggards through school each year, the school 
is saved the expense of having to teach the pupils two years 




Fig. 30. A Rochesteh School Boy Patient of the Free Dental 

Dispensaries. 

'"Handicapped in his school work, health, appearance and ability to 
secure or hold a position. It is necessary for him to leave school to 
help support the family. Who wants to employ a boy with a mouth 
such as this? We remove the handicaps and enable this lad to start 
even with his associates. This charity does not pauperize the recip- 
ient." 



Dental Inspection in Schools. 113 

the same subject. It has been said that schools expend about 
twenty per cent, of their income on this kind of double 
teaching. Another of the greatest drawbacks to successful 
teaching is from absentees. A large per cent, of absences 
from school is from toothache. This remedied, the pupil 
is more apt to be regular in attendance, and consequently, 
can better concentrate his mind on his studies. (Fig. 30.) 

Dental inspection in our public schools not only educates 
the children along these lines, but it also enables us to teach 
the parents what they can and should do for the younger 
generation in the way of preventing disease. The laity, 
being so ignorant on the subject of oral sepsis, should be 
given every opportunity, and should have impressed on 
their minds the close relation between these conditions and 
the general health. I have requested the privilege of pub- 
lishing a personal letter from Dr. Zarbaugh. It contains 
the best argument for our work in the public schools: 

Toledo, Ohio. 
Dr. Robin Adair, 

Atlanta, Ga. 

My Dear Brother Adair: Enclosed please find my effort on 
behalf of the school children of America. I could not speak the vol- 
ume that is in my heart on this subject, because ours is an empty home, 
made so by the neglect of someone in allowing a child to return to 
school who had been ill with scarlet fever, without thoroughly clean- 
ing the mouth. 

I have looked into the diseases of childhood pretty thoroughly, and 
I find that absolutely nothing has been offered the medical men in 
the way of treatment but serumtherapy, and no progress has been 
made in preventing them, except what we of the Dental profession 
are able to do in the oral hygiene movement. I believe that it is 
our greatest field in which to work for humanity. 

Ours was a bright, fair, blue-eyed boy nine years old, sick one 
week, bid us goodby after telling us that he was going to heaven, 
kissed us with a smile on his lips and passed on. 

The same tragedy is being enacted in many homes at this very 
moment, and the sad thing about it is, that it could have been and can 
be prevented. Yours very truly, 

Lyman L. Zarbaugh. 



ii4 Practical Oral Hygiene. 

IMPORTANCE OF DENTAL INSPECTION OF 
SCHOOL CHILDREN'S TEETH. 

BY DR. LYMAN L. ZARBAUGH. 

If the annual losses to the parents and guardians of the 
school children of America and to the children themselves 
were focused into a single line of figures, the result would 
look like an astronomical calculation. 

According to figures given where inspection of school chil- 
dren's teeth have been made in schools, ninety to ninety-five 
per cent, have defective teeth. 

Thousands upon thousands of dollars are wasted each 
year. Untold suffering, great loss of time in school from 
toothache, mental disturbances, etc., result because of the 
ignorance of parents regarding their children's teeth. This 
suffering and loss of time and money can be stopped very 
quickly and effectively by the inspection of school children's 
teeth by a dentist twice a year. 

To illustrate the loss in dollars, one of the thousands of 
cases is cited. A child at the age of six years erupts the 
first permanent molar. Because of faulty development, a 
small opening between the folds of enamel at the develop- 
mental lines allows decay to progress. No amount of 
brushing or anything else will save that tooth except a prop- 
erly inserted filling. Now it is perfectly plain that if that 
child's teeth are inspected at the beginning and close of the 
school year, the cavity or defect will be found, and the fault 
remedied if the parents heed the warning. If, on the other 
hand, no inspection be held, the tooth continues to decay for 
a year or more, and the child, after the tooth is nearly ruined, 
complains of toothache. The dentist is visited. He finds 
the pulp exposed or putrescent, necessitating tedious treat- 
ment and expensive restoration, costing anywhere from five 
to eight dollars; whereas, if the matter had been brought to 
the attention of the parent at the start, the cost would not 



Dental Inspection in Schools. 115 

have exceeded one dollar at most, and very likely less, to say 
nothing of the loss of time, and pain and suffering of the 
child. 

Dental inspection can be likened to the watchmen in large 
buildings and factories who make their rounds every hour, 
pulling the boxes. They are looking for fire. If they find 
it, the fire department is called and the damage is slight. 
Just so with dental inspection in schools. The damage to 
teeth would be very slight indeed. No tooth would decay 
in six months' time sufficient to cause any real trouble or suf- 
fering. 

The coming generation would never experience toothache 
and loss of teeth, if dental inspection in the schools were 
universal and the warnings heeded. People wearing artifi- 
cial teeth would be a curiosity in a single generation. If the 
fathers and mothers knew what it would mean to their chil- 
dren to be free from pain and mental disturbances caused by 
toothache, they would not only request, but demand dental 
inspection of the school children's teeth. 

Seventy-five per cent, of all contagious diseases enter the 
body through the mouth and throat, and untold thousands 
of dangerous death dealing disease germs lurk in unclean 
mouths and decayed hollow teeth. Make it a part of the 
regular school work that the children's teeth be inspected 
twice during the school year, and that they be taught the 
vital importance of a clean mouth and its relation to good 
health and a well-founded education. 

This program, if followed out, will save human lives. 
It will prevent death from snatching children from their 
mother's arms for the reason that the infectious diseases of 
childhood lurk and grow in the mouths of children many 
weeks after they have, to all appearances, recovered from 
a disease. They return to school and play with their mates, 
and spread disease and death by infecting other children, 
thus emptying the loving arms of thousands of mothers 



1 1 6 Practical Oral Hygiene. 

everv year, and instead of them having the God-given privi- 
lege of watching their children develop into manhood and 

womanhood, they have now the task of visiting a lonely 
cemetery and placing flowers on a little green mound, and 
return to a house that is not a home, but which only contains 
memories o\ what might have been, and a mass of ruined 
hopes. 

Thousands of children die every year because some child, 
who had been sick with a contagious disease, returns to 
school with a dirty mouth. Fathers and mothers of Amer- 
ica, remember this, that dental inspection in our schools, 
and tooth brushes would be much cheaper than funeral ex- 
penses and flowers, and children's laughter much preferable 
to empty arms and aching hearts. Which do you prefer? 
Won't you start a campaign in your locality for dental in- 
spection in vour school? The authorities owe it to every 
child. 



C II A PT E R VII. 

DENTAL INSPECTION AND CLINICS FOR PUB- 
LIC SCHOOLS— CONTINUED. 

III!, DENTAL HYGIENIS1 IX BRIDGEPORT. — THEMORRISTOWN 
CLINIC — THE ST. VUGU8TINE CLINIC. — THE DETROIT 
IDEA. — FORSYTH DIAI AL INFIRMARY. — IN81 RUC- 
TIONS FOR MAKING school EXAMINATIONS. — 
FORMS USED FOR INSPECTION AND 
CLINIC work. 

THE DENTAL HYGIENIST IN BRIDGEPORT. 

To the earnest, sel I -sacrificing and successful efforts of 
Dr. A. C. Fones, of Bridgeport, Conn., the dental profession 
is indebted for the greatest movement in regard to preven- 
tive dentistry. Idle event was the graduation of thirty-two 
women, on June 5th, 1 9 1 4 , as Dental Hygienists. Realiz- 
ing the great need for women to do examination and prophy- 
lactic work in schools, Dr. Fones secured the services of 
about about twenty specialists who came and lectured for a 
class. Applicants for admission to the school were care- 
fully selected. 

Dr. Fones has one of the best appointed offices in the 
world. Connected with his office is a private garage for use 
of himself and patients. This space was turned into a lec- 
ture and clinic hall. Pull details of the methods of instruc- 
tion and training employed may be found in a book, "Mouth 
Hygiene, a Course of Instruction for Dental Hygienists'' 
which contains the lectures given before these classes. The 
practical training was begun on a most ingeniously arranged 



n8 



Practical Oral Hygiene. 



manikin with ink-smeared teeth. As proficiency was attain- 
ed, children were substituted. (Fig. 31.) 




Fig. 31. 



The Fones's Method of Training Dental Hygienists by Use 
of Manikins. 



The course was only given to prove Dr. Fones' ideas cor- 
rect, and to furnish efficient help and establish a new idea in 
clinic work in Bridgeport public schools. The policy of this 
clinic is thus given by Dr. Fones: 

"On the 8th of September the work was started in our 
public schools, twenty-eight in number, and throughout them 
all we have been cordially received by the principals and 
teachers. The children have taken very kindly to the treat- 
ments and it has been our regret that we could not aid those 
in the higher grades who wished to have this service. 

u The hygienists work in pairs, as a rule, two remaining in 
the school until all the children of the first grade are given 



The Dental Hygienist in Bridgeport. 119 

treatments and some in the second grade, too. It is our 
intention to give the second grade children one good clean- 
ing during the year in order to have a fairly clean zone 
ahead of our first grade children. 

"The supervisors give tooth-brush drills, oversee the work, 
look after supplies and give class-room talks to the first 
and second grades. Each operator is supplied with an S. S. 
White portable chair, a cabinet, stool and dental engine, 
besides all the necessaries for sterilization in their work. 
Their chairs are placed anywhere in the school where they 
are out of the way, have plenty of light and running water. 
On stair landings, where they are deep enough to give ample 
room for marching lines; in the basement, if it is warm and 
dry and sufficiently light; in cloak-rooms or in hallways, we 
can always find a place to put the chairs. (Figs. 32 and 

33-) 

"As they advance to the second grade a corps of dental 
hygienists will take care of them in their second year of 
school life. Again in the third year, and so on up to and 
including the fifth grade. A few additional women will be 
added to the numbers when needed, so that a child will have 
its teeth kept clean and polished during the first five years of 
its school life. If such a system is adopted we will have 
from the year it is started an army of children with clean 
mouths in the first grade advancing the next year to the next 
grade. Again this clean mouthed army will advance into 
the third grade and so on up to the fifth, pushing before 
them those who have innumerable decayed teeth. In five 
years we should have all the children in all grades with 
will have clean mouths and sound teeth. And if this edu- 
cation and training had meant all that it should, in eight 
years we should have all the children in all grades with 
healthy mouths, and the new-comers entering into a defi- 
nitely formed system. 



The Morristowx Clinic. 121 

"Now possibly some of this sounds theoretical, but let us 
look at some facts and figures that may prove we are trying 
to be exceedingly practical. In the first round through our 
public schools the corps of eight dental hygienists cleaned 
and polished all of the teeth of the children in the first 
grade, and by working after school hours and on Saturday 
mornings for many of the children in the second grade. 

"In closing, I wish to say that this work in the school is 
chiefly woman's work. The children climb up into the dental 
chairs with but little fear, as they have confidence that the 
women will not hurt them. I doubt if this same trustfulness 
would prevail if standing beside the chairs were eight men 
instead of eight women. There will never come a time in 
our civilization when there will be no decayed teeth, but 
there will come a time, and it is not far distant, when the 
majority, instead of the very small minority, will have 
mouths free from dental decay." 

One of the first requirements in establishing a dispensary 
is to eliminate those who are not entitled to free dispensary 
care. This is accomplished by having the parents of the 
patient sign a card authorizing the services which is so 
worded as to eliminate the well-to-do child. 

The most important part of the dental clinic is not its 
mechanical appliances, not its dental operators, not its oper- 
ations, but the teaching of oral hygienics which should em- 
anate therefrom. 

If a child be obstinate or backward in regard to keeping 
a clean mouth, the nurse should go into that home and in- 
struct the parents about the importance of clean teeth, 'and 
see to it that the child is kept under observation until mouth 
cleanliness is established. Such social service is now the 
most approved in the modern hospital. 

THE MORRISTOWN CLINIC. 

A dental clinic was carried through to a successful issue 
in a very short time by several dentists in Morristown, N. Y. 



122 Practical Oral Hygiene. 

This work was accomplished largely through the efforts of 
Dr. H. N. Dodge, who gave the plan publicity by practical 
suggestions given the daily paper. After gaining the atten- 
tion of the public, Dr. Dodge and his associates gained an 
ally in The Bureau of Social Service. Finding that the 
state law would not allow their municipality to appropriate 
money for this clinic, they secured popular subscriptions to 
fit up a first-class operating room. Its maintenance at pres- 
ent is paid for by the same means. The clinic was incor- 
porated with ample legal power under the title of "The 
Morristown Free Dental Clinic Association," January 15, 
19 1 5. The high-class of the officers and trustees at once 
gained the favor of the school authorities, the medical so- 
cieties and the public. Dr. Dodge says that the next legis- 
lature will pass a law enabling the municipal authorities of 
Morristown to pay the current expenses of this clinic. 

The operating room of the clinic was equipped with a 
Forsyth unit dental chair, the first to be used outside the 
Boston institution. The experience of other clinics was ac- 
cepted, and a salaried operator was placed in charge. Dur- 
ing the clinic hours the nurse of the public schools becomes a 
dental nurse. The walls are decorated with tablets bearing 
appropriate lessons in oral hygiene. 

The above description furnishes many new ideas and 
shows what a well-planned campaign can accomplish in a 
short time, even in the face of financial difficulties. 

In the carrying forward of the work, various operators 
may have to handle a case before it is finished. As every 
dentist has some pet way of doing things, it is first essential 
to establish and tabulate on printed card a routine series 
of treatments. Thus the patient can be carried through 
any treatment with several operators without any hesitation 
or embarrassment of either operator. 

The operation of free clinics for dental service is dis- 
cussed here solely for the reason that they can be made the 



The Morristown Clinic. 123 

greatest factor for oral hygiene teaching. The question has 
arisen that this part of the work and the great opportunity 
it affords is often neglected. After the clinic has been es- 
tablished, the local dental societies should see that all new 
school buildings planned have a room fitted for dental clinic 
work. 

The ideal place for and the ultimate location of the free 
dental clinic must be in the school building. However, this 
is not always convenient or possible. Morristown used 
the former quarters of a photo studio. Some have found 
quarters and free rent in the city hall, or in the city hospital. 
Others have used the various dental offices, but this proposi- 
tion, while it seems feasible, has always delayed the work, 
and if persisted in, will surely kill any effort toward the es- 
tablishment of a proper clinic. In the plan of Bridgeport, 
neither room nor elaborate equipment is necessary. Here, 
they have proved that a stair-landing serves a good pur- 
pose. Study the illustrations given of this method. 

We call these clinics free and yet it is most desirable that 
a small charge be made so that the recipient will not be 
offended by accepting charity. Absolutely free things are 
seldom appreciated, but if something is contributed to the 
cost, it is human nature to attach more value to the service. 
Another point in favor of even a five or ten cent charge is 
that the aggregate amount will pay for the material pur- 
chased to be used in the clinic. However, this does not 
mean that the clinic should at any time become self-support- 
ing. Where it is not desired to make any specific charge for 
operations, but where money must be raised, it might prove 
profitable to have a receptacle conveniently placed, in front 
of the chair, in order that those who appreciate the work 
and feel so disposed, may contribute what they feel able to 
pay. A properly-worded card published in newspapers or 
sent to patients will help to fill this box. 



124 Practical Oral Hygiene. 

An editorial in the New Jersey Dental Journal for Feb- 
ruary, 19 1 5, furnishes some matter which is most sugges- 
tive : 

"Limiting the eligible patients at the clinics to children of 
school age and the investigations conducted to ascertain if 
the case is really a deserving one are wise precautions in- 
tended to prevent abuse of the charity by those who can 
afford to pay a regular dental fee. In this way the class 
of patients for whom the clinics are conducted are assured 
of treatment and the greater good will be derived by the 
patient and by the community and by the dentists of the com- 
munity, for the interest aroused by the work of a clinic is 
bound to awaken parents who can afford to pay dental fees 
to the importance of caring for the teeth of their children/' 

Dr. N. S. Hoff has called our attention to the statistics 
of the various dental clinics criticising the reports because 
they show such a small number of operations under the 
head of "cleaning teeth," as compared with other work done. 
His suggestion is that every patient present should have his 
teeth cleaned thoroughly, and should be instructed in oral 
hvgiene. Says Dr. Hoff, in an editorial in the Dental Dis- 
pensary, August, 191 2: "It would seem that nine-tenths of 
the time and energy of the dentists in charge of these clinics 
had been expended in relieving the pain of diseased teeth, 
and repairing the loss of tooth substance. We arc justified 
in saying that the amount of real hygiene instruction green 
in these clinics is far short of what it should be, for the ex- 
pense of money and sacrifice of time put into it by profes- 
sional men, of course actual repair and relief operations 
must be made, but the chief aim of these clinics ought to be 
to impart instruction that will help these children place the 
proper value on their teeth, and compel them to give some 
measure of attention in the way of a systematic mouth 
toilet." 



The St. Augustine Clinic. — The Detroit Idea. 125 

THE ST. AUGUSTINE CLINIC. 

As'evidence of improvement along the line of suggestion 
of Dr. Hoflf may be cited the report of the free dental clinic 
of St. Johns County, Florida. From February, 19 14, to 
February, 191 5, there were five hundred and thirty-seven 
(537) individual patients treated, and of those four hun- 
dred and three (403) had their teeth cleaned. The estab- 
lishment of this clinic is of worthy record. 

Mr. J. T. Dismukes, a prominent citizen of St. Augus- 
tine, Florida, offered a donation of $1,000.00 towards the 
establishment of a free clinic for school children of the 
county, providing the county would furnish the outfit and 
office. It is to the credit of County Superintendent D. D. 
Corbett, that he could present the matter before the board 
of education in such a way that the necessary money was 
forthcoming. Mr. Dismukes gives $1,000.00 annually for 
twenty-five years to pay the salary of the dentist in charge. 
Dr. A. M. Sellers, the efficient dentist in charge of this 
work, says that the records show the attendance at school 
has improved and that the general efficiency of the children 
is better. 

The same means is available for any town or city. All 
dentists have some wealthy patient who probably would be 
pleased to help his community in this way, if only the mat- 
ter were presented in a proper way. 

THE DETROIT IDEA. 

In an address delivered (1914) before the Michigan 
Dental Society, the superintendent of the Detroit public 
schools said: "We are having placed in all of the build- 
ings which are to be erected in the future, well-equipped 
clinic rooms, that is, rooms specially designed by the archi- 
tect in preparing the plans, where we may have in every one 
of our new buildings these dental clinics. We do believe 
that the health of the children is of permanent importance, 



126 Practical Oral Hygiene. 

and we are trying in every way to foster that health. I 
believe that the responsibility for this kind of work should 
be definitely fixed upon the department charged with the 
general health of the entire city. Only a few months ago, 
as the result of a suggestion of your Dental Association 
of Detroit, and through the active interest of one of your 
number, who happens to be one of the school inspectors of 
this city, the teachers were instructed to include in the regu- 
lar marks which are sent home with the pupils, a mark as 
to the personal and the oral hygiene of the pupil. While I 
wondered somewhat as to the effect of this particular change, 
and as to the spirit in which this would be received by the 
patrons, I am very well satisfied now that that kind of work 
is helping, and we are accomplishing in that way some of 
the things which were indicated to-night; that is, we are 
showing in a very emphatic way to the parents of the chil- 
dren coming to the public schools, that there is something 
which must be looked out for in addition to the intellectual 
progress of the child, and that if the personal hygiene of the 
child is unsatisfactory, or the oral hygiene is unsatisfactory, 
there is something which needs attention just as emphatic- 
ally as if the work in arithmetic or reading or spelling, or 
any other branch, is unsatisfactory. I had a number of in- 
dignant messages after the first reports were received. A 
number of parents were decidedly insulted, and came to see 
us concerning this departure. They said it was an outrage, 
and that the teachers should apologize to the parents for 
sending reports of unsatisfactory conditions. But I have 
noticed, on the other hand, that in many cases there has been 
very greatly increased attention given to those very things. 
And human nature being as it is, when the children discover 
that if those things are neglected there is going to be a mark 
of 'unsatisfactory' on their report, which is otherwise spot- 
less, there is apt to be some very strong pressure on the part 
of that child in the way of having these defects eradicated. 



The New Forsyth Infirmary. 127 

We instructed the teachers that if the dental inspectors re- 
ported to them that there were faulty conditions in the 
mouth, until those faulty conditions had been corrected, and 
evidence that that correction had been made received 
through reports from the home dentist or from the dental 
clinic, the report 'unsatisfactory' was to be continued." 

This view is correct, and it is to be hoped those who have 
such work in charge will realize the facts, and take advan- 
tage of their great opportunity for spreading the gospel of 
clean teeth. 

THE NEW FORSYTH FREE DENTAL INFIRMARY. 

The Dental Infirmary erected in Boston, and dedicated 
to the needs of children is now the model institution for all 
the world. 

The site and building cost half a million dollars, and is 
endowed with $1,000,000.00 for its maintenance. It is 
furnished with the latest and best dental equipment, includ- 
ing a lecture hall for the teaching of oral hygiene to the 
public. The institution is doing what the trustees started 
out to accomplish, that is, an aid for "A better looking, 
more perfectly developed race." (Fig. 34.) 

Dr. G. W. Clapp, by editorial in the Dental Digest, thus 
discusses the oral conditions in their relation to community 
hygiene : 

"In America we have not yet reached so enlightened a 
condition; our oral hygiene clinics are mostly conducted as 
charities by the efforts of a few noble-minded practitioners 
and the aid they solicit. In the light of experience here and 
abroad it is probably safe to say that this is neither a just, 
a wise, or a safe foundation for such enterprises, save in 
instances like the Forsyth Infirmary, where a great endow- 
ment insures permanency and adequate equipment. Com- 
munity oral hygiene is not the burden of the dental profes- 
sion. It may be our duty to prove its merits, to show what 



The New Forsyth Infirmary. 



29 



it can do for the community and to assist in its establish- 
ment by all the means in our power. But to look forward 
to its permanent conduct by dentists is to insure that it will 
fail of its greatest usefulness. 




Fig. 35. Interior View of the Forsyth Dental Infirmary. 



"Community oral hygiene is of right a community enter- 
prise. It has more to do with the health of the persons 
comprising the community, with their economic efficiency, 
and the return which they shall make to the community, than 
almost any other single measure. In the minds of those 
who have studied it most, it will prove an economy rather 
than an expense. It is not impossible that within the child- 
hood of those who benefit by it, it will save its cash cost 
to the community in freedom from disease, in improved at- 



130 Practical Oral Hygiene. 

tendance of children at school, in greatly improved mental 
ability, and in reforming juvenile criminals." 

FORMS USED FOR INSPECTION AND CLINIC WORK. 

Dental inspection and record must preceed any attempts 
towards the establishing of a dental dispensary. The litera- 
ture and forms as used as Cleveland, Ohio; Rochester, N. 
Y. ; Denver, Detroit, and Cincinnati furnish efficient forms, 
some of which are illustrated. 

INSTRUCTIONS FOR MAKING DENTAL EXAMINATIONS IN THE 
CLEVELAND PUBLIC SCHOOLS. 

Examiner should work in harmony with the principal of the school 
and should himself make all arrangements for the examina- 
tions with the principal. 
Examiner should secure from the principal the use of one table, two 
chairs, wash basin, hot and cold water, and a suitable place 
in which to keep his outfit from week to week. 
Examiner should see that principal understands the instructions for 
her teachers, viz: The teacher should insert carbon paper 
between the first two blanks and then proceed to supply 
the 

School 

Date (of examination) 

Name (of pupil) 

Address (of pupil) 

Age Grade Room No. 

for each pupil. Always in duplicate; arranged as the chil- 
dren sit in rows in their class. The children should be 
supplied to you for examination in the same order in which 
the blanks have been prepared. Always keep one or more 
of the children in line but never have to exceed five wait- 
ing; one or more dispels fear, too many provoke mirth, 
teacher should not detach blanks. The blanks should 
come to you in pad form. When you have made your 
record, using same carbon paper as teacher, remove the 
top sheet, giving this original to the pupil, fold over the 
pad the duplicate and later send same to the secretary 
of examinations. You will find that one hundred exami- 
nations will be all that you can care for in one morning 
of three hours until you have had some experience. There 



Forms Used for Inspection. 131 

will be sent to each school with examination blanks, four 
carbon papers so that four teachers may prepare for com- 
ing examinations at the same time. These carbon papers 
should be left by the teacher in the pad of blanks. You 
will need them for your work. When you have finished 
examining for the day, be sure to return the four carbon 
papers to the principal for future use. 

Examiner should be prompt in attendance. 

Examiner should have his person neat (wear office coat) and above 
all his hands and nails should be mechanically clean. He 
should see that his mouth is clean as an example, and his 
breath should be sweet. 

Examiner must not use tobacco when on school property. 

Examiner should use a pad of blanks for each room. 

Examiner should examine with his back toward a w r indow, that he 
may have good direct light in the pupil's mouth. 

Examiner must keep his hands out of pupil's mouth. 

Examiner must not use any instrument except a mouth mirror. 

Examiner must not use a mirror but once until resterilized. 

Examiner should see that vessels containing carbolic acid and alcohol 
are labeled at all times. 

Examiner should see that sterilizing is properly done and that mirrors 
are free from both carbolic acid and alcohol and are at a 
temperature that will be comfortable to the mouth and not 
fog the glass. This will necessitate frequent change of 
hot water in the last glass. Proper sterilization of mirrors 
for this work will consist in: 1st, Washing with a brush, 
in hot water and soap. 2d, Immersion in carbolic acid 
solution (as provided which is 1 to 64) for at least five 
minutes. 3d, Immersion in alcohol (95%) (alcohol must 
be at least one-half inch deeper than carbolic solution). 
4th, Immersion in hot water until used. This water 
should be changed at least once for every thirty mirrors 
passed thru it. Mirrors should be used w T et and not touch- 
ed with the hand, napkin or otherwise. 

Examiner should always leave his outfit clean and as nearly ready 
for use as possible. Carbolic acid solution and alcohol 
should be thrown into sewer at close of day's work. 

Examiner must provide: Six (6) mirrors (Ash mirrors may be had 
for 50c each or 6 for $2.50, at Ranson and Randolph's.) 
Three large drinking glasses for alcohol, carbolic acid, and 
water. Six (6) pencils. Towels for personal use. Soap. 
Basin and brush for scrubbing mirrors. One tray to re- 
ceive soiled mirrors. An assistant to sterilize the mirrors. 



132 



Practical Oral Hygiene. 




Fig. 36. Proper Arraxgemext of Table for School Ixspectiox Work. 



Examiner will be furnished with a card of appointment which he 
should carry on his person. 

Examination blanks, alcohol, carbolic acid, and labels for 
the same will be furnished and will be delivered to the 
principal of the school. 

The Oral Hygiene Committee will pay assistants at the 
rate of 50c per half day which means three hours' work. 
Should examiner be unable to provide an assistant, one will 
be furnished him upon request. 
Do not examine Kindergartens. 

Examine 1st grades first, and 8th grades last. Never force 
a child to submit to examination if parents object. If par- 
ents object, so mark his chart and send original home. 
If child is afraid have him first see you examine another, 
after which you will have no trouble. 

DETAIL OF A DAY'S WORK. 

Examiner and his assistant should be at the school at 8:15 a. m. and 
should at once notify the principal that he will be ready 
for work at 8 130. 

Examiner and his assistant should prepare his table after the fashion 
shown in the enclosed blue print. Begin work promptly 
and continue steadily until recess, at which time a few 
minutes relaxation in the fresh air will be found beneficial. 
After recess resume work until close of morning session. 
Have assistant clean and store all utensils properly. Make 
out your report and wrap with pads of examinations. Pay 
your assistant; the society will pay you. Have her re- 
ceipt for it on your report. Inform your principal of your 
next appearance and depart. In most convenient manner 
send your report and blanks to the secretary of Examina- 
tions. Should you need any supplies notify Sec'y of Exams 
at once. Call Main 517. 

Examiner should not ask pupil if he has a family dentist. 



Forms Used for Inspection. 



i33 



DENTAL EXAMINATION OF SCHOOL CHILDREN, CLEVELAND.'OHIO 

MADE UNDER THE AUSPiCES Of 

The Cleveland Dental Society, The Ohio State Dental Society and The National Dental "Association 

FRONT OF TEETH. 
1 a 8 4 6 7 8 10 xi ia id 14 16 10 

mmm 



UPPER. 



82 31 30 29 23 27 26 26 24 23 22 21 20 19 18 17 

RIGHT SIDE 



LEFT SIDE 

a. » c o r re 



School 

Date 

Name 

Address 

Age Grade Room No. 

Condition of Mouth Good Bad 



.191. 



FRONT OF TEMPORARY TEETH 

T 3R9P0NML X 

BACK OF TEETH. 
8 9 



Condition of Gums 
Use Tooth Brush ? 
Teeth FHled ? 
Malocclusion ? 

REMARKS : 



Good 
Yes 
Yes 
Yes 



No 
No 
No 




25 24 

EXPLANATION OF MARKS ON DIAGRAM. 
through tooth means cavity or cavities. 



of crown. 
X — Permanent tooth lost. 

-.v. »I u Pi V? ENTS ^A sound body and sound mind are usual and frequent companions. Schools are therefore ooncerned 
witn both. Neglect in care of the teeth is the cause of so much ill health that school authorities everywhere are seeking 
co-operation with competent dentists. Our Board of Education has arranged with the local dentists for a free examination 
,£??. of a11 8cho °l children. The report on your child is shown above, 
•n u • *" e ^* min ation and report (though not complete) is not an attempt to interfere with your private matters. 'They 
will bring to the majority of the parents first knowledge of the fact that their children's teeth need the attention of a 
dentist. It is our belief tha-j all parents will be interested in having their regular dentist look after the defects pointed 
out by this report. Very truly yours, 

ovr») W. H. ELSON, Superintendent of Schools. 



Fig. 37. Cleveland Dental Examination Form for School Children. 



i34 Practical Oral Hygiene. 



ABOUT TEETH. 
Good Teeth, Good Health. 

Without Good Teeth there can not be thorough 

MASTICATION. 
Without thorough mastication there can not be perfect 

DIGESTION. 
Without perfect digestion there can not be proper 

ASSIMILATION. 
Without proper assimilation there can not be 

NUTRITION. 
Without nutrition there can not be 

HEALTH. 
Without health what is 
LIFE? 

Number of Teeth 
There are twenty teeth in the first or temporary set — 10 upper and 
10 lower. In the permanent or second set there are 32 teeeth — 16 upper 
and 16 lower. 

Their Purpose. 
The teeth are for ornamentation, for grinding the food, (thus pre- 
paring it for proper digestion), and assistance in talking. They should 
last to the end of life. 

How Lost. 
By decay and loosening. Decay is caused by allowing food to remain 
about the teeth and by poor health. Teeth become loose by a deposit on 
them at the edge of the gum, called tartar. 

How Can Decayed Teeth and Diseased Gums be Prevented? 
By cleaning the teeth with a tooth brush and water on arising in the 
morning and before going to bed at night. A quill toothpick properly 
sharpened, should be used after each meal. A toothpowder used on the 
brush will assist in cleansing the teeth. 

The essential ingredient in all good tooth powders is precipitated chalk. 
This may be flavored to suit the taste. The following formula is con- 
sidered a good one : 

Precipitated Chalk 3 % ounces. 

Pulverized Castile Soap % " 

Garantos 1 grain. 

Flavor with Oil of Peppermint, 

Sassafras, Wintergreen or Cinnamon 5 drops. 

The slow and thorough chewing of the food helps to preserve the teeth 
and keep the mouth in a healthy condition. 

Every person should have his teeth examined by a competent dentist 
several times a year. 

Cleanliness is the best guard against disease. 



Fig. 38. Back of Form. Fig. 37, for Dental Examination of School 

Children. 



Forms Used for Inspection. 



135 



BOARD OF HEALTH 
Dental Inspector's Daily Report 

School 191 

Grade No. Examined 

No. needing immediate attention 

( Good 

General condition found < Fair 

( Bad 

Remarks 



D. D. S. 



Fig. 39. Form Used for Daily Report of Inspector. 



CINCINNATI DENTAL ASSOCIATION 

I, parent or guardian of 

herewith request the nurse of the Department of Health to 
take my child to Free Dental Clinic for treatment, and give 
her power to act according to the advice of the attending 
physician. 

Signed : 



Treated by 



Visits to 



Results 



Family Dentist 
Clinic 



Home 
Clinic 
Other 



Recovered or improved 
Refused treatment 
Pending 



REMARKS 



Date of Discharge 
Xurse 



Fig. 40. A Record Form Used at Cincinnati. 



136 



Practical Oral Hygiene. 



school. 



1910 



Grade Room Number 

Name Age , 

Address 



8 7 6 5 4 3 2 1 



7 6 5 4 3 2 1 



12 3 4 5 6 7 8 



12 3 4 5 6 7 8 



Does Child use Brush? 

Condition of Mouth? 

Condition of Gums? 

Condition of Temporary Teeth? 

Family Dentist? 

Teeth Filled? 

Mai-Occlusion ? 

Remarks 



Yes 

Good Fair. 

Good Fair. 

Good Fair. 

Yes 

Yes 

Yes 



Bad. 
Bad. 
Bad. 



No. 

No. 
No. 



Disposal of Case. 



Examined by Dr. 



Fig. 41. Ax Examination Form Used at Cincinnati. 

To begin school inspection or clinic work it is a good idea 
to secure a collection of the forms as used in several of the 
larger cities. A letter addressed to the Board of Health 
in each city with such a request will generally receive prompt 
attention. From such a collection of material can be se- 
lected forms suitable for the new work. The tendency at 
first is toward getting too much matter on the form. This 
must be guarded against and the most simple forms possi- 
ble should be selected. 

The most important form is the one to be sent the parent. 
This should always bear some simple truths about the teeth 
and their care. This form is best printed on cardboard, as 
a paper sheet is sooner destroyed. After the forms are 
selected the next step is to adopt some permanent filing sys- 
tem as the accumulated statistics are valuable. 



Forms Used for Inspection. 



137 



ROCHESTER DENTAL SOCIETY -- FREE DENTAL DISPENSARY No. 2 
Card of admission on representation or statement of patient. 



Name \J^, 



tt^v^ (Sh^v^lA 



~ La ^ \w^ju>a Sv . 



0«.^>h|iv- School N^o.VU, 


Grade ^ *""" 


Te.ch.r \MJJL, a. S^V^ 


—* f fc^n^ 


Where Bom *U^.> m 


Age I ^ Color IaTwJLv. 


Ho. In Family ^ Income \ ^ 


Rent j 1 /^ 


Medlca. Attendant ^ f ^T < y^~. 



Father 


Mother 

u. 


Applicant 


Mental 


Ho. Teem 
1% 


Defective 

7 


Percent 


Dentifrice T 


Brush! 


Irrejular' 


Sa 1 va * 


Mcutr Breather? 




Remarks 



This is my J — _ appi»cation to this Dispensary in ihe year ^H * ^- I have Oeen an applicantto no other Dispe-ii -., - 

the year A\ ^ (or to the following D.spensaries* T*» , ' < «-*- ^ Lw-w ^J^L\ , — *~^a » 
The foregoing statement Is In all respects trus; 

Signature 



of app.icart Spirt. 6&. & . ?U<*^ri4*S. 



— estigateo 



\\XuLy ^X-^WeV. *»«~»» 3^ UAJtW S\'. Telephone No. IHgQ /^ 



Fig. 42. Card of Admission. 



IS5B2I 3W 



ygp^ n ITnjiTilTf 1 ^ 

55 ! * • i i ; ^ 1 1 J 1 5 % ' 

? i ? 1 £ J 1 1 I 5 I ! I = J I 





Fig. 43. Back of Card of Admission. 



138 



Practical Oral Hygiene. 



ies 



Rochester Dental Society— Free Dental Dispensar 

O Clifford, Thomas and Woeger Streets 
' School No. 2<i 

0~32 S. Washington Street 
Rochester Public Health Ammo. 



Sclo St. cor. University Ave. 
School No. 14 

Name JUaJVAJ .fiov^VSV^ 

Address .1. X. . Cm/U/VM? . M~. 

No. In family . .5T. . . . Income /.O.-rT 
Employer J.4 ! L .^LrV<-M^ 

Rent . O . Vr: . . .flH 5 ^ . .rTTS. , 

School No. . J. fr 

Sent by Jfe^ . IX. &fett>~. 



Monday 
Tuesday 
Wednesday 
Thursday 
Friday- 
Saturday 


'hffo 










¥± 










'1 


IH 







Signature of Parent or Guardian 
ALWAYS BRING THIS CARD W r ITH YOU 



'(over) 



Fig. 44. Engagement and Record Card Used at Rochester. 



PENALTY FOR FALSE REPRESENTATIONS. 
Section 25, Chapter 368, Laws of 1899. 

Any person who obtains medical or surgical treatment 
on false representations from any dispensary licensed under 
the provisions of this act, shall be guilty of a misdemeanor, 
and on conviction thereof shall be punished by a fine of 
not less than ten dollars and not more than two hundred 
and fifty dollars. 

(Imprisonment until fine be paid may be imposed. Code 
Crim. Pro. Section 718.) 



Fig. 45. Back of Fig. 44. 



Forms Used for Inspection. 



i39 



In writing about the dental clinics of Detroit, Dr. Oak- 
man says: "All lectures are illustrated by lantern slides. 
When possible photographs are taken of interesting cases, 
both before and after treatment, and preserved as a matter 
of record. 

"Weekly reports of all inspections and operative work 
are sent to the chief inspector, and a duplicate to the board 
of health. An imaginary fee is placed on all work done 
in the clinics, whereby we are enabled to estimate the rela- 
tive value of each operator to the department. Without 
this we could not arrive at a proper conclusion as to the 
value of the work done by each individual." 



Detroit Board of Health 



Many children neglect to do this; then it becomes neces- 

To Parents and Guard.ans: "'* t0 •*« J ,he , t !f h , c '" ned and repaired ****"*** 

n; c -,c „f .i,» ....1, »,,.,. k— a «tu j- The Board of Health has gone over the whote problem 

lhf ^„ e ", of the ,€eth have been named Tbc dlsease 01 of the care of the children's teeth and has prepared a plan 

me people which . { bt . Vievv win aid the cn iidren greatly in promoting 

The widespread existence of this disease and the great goo( f health 

»f atvasM affl» ■• - - = „ - a-iiAx'cs afcsxaer - 

GOOD HEALTH DEPENDS UPON GOOD TEETH I. You are asked to buy a tooth brush for each child in 

BECAUSE the family. 

1. There cannot be health without nourishment. „* Yo " a " asked ,0 . s f. e £j J 6 c ^ ld us " this J.°° TH 
, _. . . , . , . , BRLSH DAILY, especially before going to bed at night. 

2. There cannot be nourishment un ess the teeth break ■> ir _. . t •.-. j . / •■ 
up (chew) the food so that the body can digest the food. . * * ou are "^"^ to take your child to your amily 
\" , ' . . . •■ , ■ . dentist for examination and for treatment If circumstances 

3. There cannot be good digestion unless the teeth are do not-permit consulting a dentist at his office, the efcM 
able to break the food, and bad teeth cannot do good work. may be treated free at one of the following dental clinics. 

4. If there is not good digestion there cannot be good You are asked to doihis NOW: 
health. Medical investigations show that much of tfve disease _ - -- - 

of the teeth can be PREVENTED; also that the younger the ?«?* * *f *™.T +? *■• ! : "" »* 1: ^ :0 ° £* 

child when the teeth are cared for, the greater the knefit S5^£*?£JL"S£: \ " " " SSSKSS SS 

All this means that if the first, or temporary set of teeth, Gr lce Hospital, John R. ud Willi. « : oo-ii;00 1 ;03-4;oo Daily 

could be kept free from disease, the s«cond or permanent set Neighborhood Settlement. 4th ft Porter 8:30-12:00. 1:00-4:00 Daily 

of teeth would be practically sound. Solvay Guild Hall. Delray »J0-12:00. 1:00-4:00 Daily 

Children enter school life just before or during the most Franklin St. Settlement, Sl» Franklin 8:30- 2:00. Hon., Wed. & Sat. 

important dental period; namely, the cutting of the FIRST Greuael School, Moran ft Medbury So 8:30^12:00. 1:00-4:00 Daily 

MOHR TOOTH. THIS IS THE FIRST PERMANENT Harper Hoapital, 300 John R ,8; 30-12:00. 1:00-4:00 Daily 

TOOTH Houae of Providence. Blvd. ft 14tb St 1*30-12:00. 1:00-4:00 Daily 

This first tooth Of the second set will not be healthy and E"« Side Settlement. 101 Superior Ave 8:30-12:00 D„ly 

sound if the first set of teeth is decayed or neglected. The • 

other teeth of the second set will not be healthy if this first 

molar is decayed. Date , 

The one great cause in all decay of teeth is THE FAIL- 
URE TO KEEP THEM CLEAN. Dear. 

There was a time when the wheat used for flour was not You are hereby notified that the dental examination made 
so finely powdered as it is today, and when modern inven- 
tions had not robbed bread of a coarseness that made the of :...,.. .under the direction of the 

teeth clean and strong by chewing. The fine y powdered ^. . •-• — ....... . . , 

wheat flour bread clmgs to the teeth and sets up ferment.- Detro,t Board of ' rfea,th shows °«ess.ty ** treatment for 

tion. This causes decay of the teeth. This decay goes on 

faster during the night than during the day. " 

Teeth SHOULD be cleaned after each meal, but MUST . , 

prevented" 1 ^'^ ^^ *° ^ **** "'^ * ***** " * ^ Please consult »«•*-*■•" " 

Teeth can be cleaned by BRUSHING or by passing silk Principal 

floss between the teeth. ' 

, School. 



Fig. 4G. A Two-Page Form of Information Used by Detroit. 



140 



Practical Oral Hygiene. 





DETROIT BOARD OF HEALTH 

WEEKLY REPORT DENTAL CLINIC 

nPTROIT. 


191 


PATIENTS 


.2 
I 


<G 


(35 


I 


§1 


II 

Kit 


i] 


I 

■H 


n 


II 


Jl 




Extracted 


3 


£ 


| 




1 


5 


No. 

ClKI 




































Mnn. A. M. 
Tiles. A. M. 
W^rl A M 


1 

1 


P. M 


Clinic 




> M. 




P.M. 




Th... A.M. 
Fri. A. M. 


P.M. 
P M 


NURS 


;E 




[) n <5 


Sat A- M. 


1 


P. M. 


ftDrDATAD 



































Fig. 47. Detroit Weekly Report Dental Clinic. 



Dr. Henry F. Hoffman furnishes the author the forms 
used in the city of Denver. He writes: "We think our 
plan more nearly meets the ideal than any other possible 
arrangement, as the school authorities have better control 
over the children than even the parents in many instances. 
Politics are eliminated to a greater extent than would be 
possible in a purely municipal clinic, and it is relatively easy 
to restrict patrons to those who are really entitled to its 
benefits. 

"The Denver School clinic is now operated entirely by 
the school board, the Denver Dental Association having 
released the management of it for the past year, although 
the profession still takes an active interest. The plan which 
is in operation here may be adopted to advantage by any 
community." 

A few of the Denver forms are shown. Those not 
shown are similar to those illustrated of other cities. 



Forms Used for Inspection. 141 



DENVER PUBLIC SCHOOLS attendance department 

School District Number One, in the City Margaret T. True. Supervisor 



ind County ol Denver, Colorado. 



MEDICAL INSPECTION 



Instructions Regarding Care of Mouth and Teeth 

The physical examination of school children shows that in many in- 
stances the teeth are in a decayed and unhealthy condition. 

Decayed teeth cause an unclean mouth. Toothache and disease of the 
gums may result. 

NEGLECT OF THE FIRST TEETH IS A FREQUENT CAUSE OF 
DECAY OF THE SECOND TEETH. 

It a child has decayed teeth, it can not properly chew its food. Im- 
properly chewed food and an unclean mouth cause bad digestion, and 
consequently poor general health. 

If a child is not in good health, it can not keep up with its studies in 
school. It is more likely to contract any contagious disease, and it has 
not the proper chance to grow into a robust, healthy adult. 

IF THE CHILD'S TEETH ARE DECAYED, IT SHOULD BE 
TAKEN TO A DENTIST AT ONCE. 

Each parent or guardian is asked to assist in this work which means so 
much for the future of the children. 

1. You are asked to provide a toothbrush for each child in the family. 

2. You are asked to see that the child uses this TOOTHBRUSH 
DAILY, especially before going to bed at night. 

3. You are asked to fill out and sign the attached form so that the 
school nurse may give any assistance required in any case. This will be 
regarded as confidential. 

Approved by 

WILLIAM H. SMILEY, DR. PEARL WHEELER DORR, 

Superintendent. Medical Inspector. 



Fill Out and Tear Off this Slip and Return it Immediately 

191. .. 

To the principal of School 

A 

a pupil in Grade is receiving treatment at 

Dr or at 

Dental Clinic, Longfellow School. 

B. I desire a pupil 

in Grade to receive dental treatment at Dental Clinic, Longfellow 

School. 

can 
I assume the responsibility of such visits. I can not pay minimum cost 
of treatment. 

Parent or Guardian. 

Fig. 48. This Card is Given the School Children of Denver. 



142 Practical Oral Hygiene. 



DENVER PUBLIC SCHOOLS 

School District Number One in the City 

and County of Denver, Colorado 

WILLIAM H. SMILEY, Superintendent 

School. Denver, Colo., 

Mr 

Dear Sir: 

An examination of 

made in compliance with the School Law of Colorado 

seems to indicate defectiveness 

The law requires examination by some competent physi- 
cian, and treatment if necessary. Will you kindly have 
such an examination made, and return this notice with the 
physician's report properly made out on the back of this 
card. Respectfully, 

Principal. 

Fig. 49. The Denver Examination Card. 



REPORT OF PHYSICIAN 

I have examined in accordance 

with your notice to the parent, and find the following con- 
ditions and have instituted the treatment as noted. 



(Signed) 

Physician 

Address 



Fig. 50. Opposite Side Fig. 49. 



Forms Used for Inspection. 143 



•TOOTH BRUSH DRILL 

Attention : 

(All in line, elbows close to side, with brushes in right hands and 
cups in left.) 

1. Ready Dip. 

2. Outside surfaces. (Brush inserted under cheek and teeth closed. 

Motion, circular including upper and lower teeth and gums.) 
Left Side— Ready— (Count) i— 16 Dip 
Right " " " 1 — 16 " 

Front " " 1 — 16 " 

3. Inside Surfaces. (Mouth wide open, straight motion, front to back.) 

Upper Left Side — Ready — (Count) i — 16 Dip 

Right " " " 1 — 16 " 

" Front " 1 — 16 " 

Lower Left Side — Ready — (Count) i — 16 Dip 

Right " " " 1— 16 " 

" Front " " 1 — 16 " 

4. Chewing Surfaces. (Scrubbing vigorously.) 

Upper Left Side — Ready — (Count) i — 16 Dip 

Right " " " 1— 16 " 

Lower Left Side — Ready — (Count) i — 16 Dip 
" Right " " " 1 — 16 " 

5. Rinse brush. (Shaking off excess water on edge of cup.) 

X. B. — Counting by leader should be rather brisk, but even and allowing 
plenty of time for dipping and shaking brushes. 

Materials : 

1. Tooth Brushes — not too large for children's mouths. 

2. Individual cups (paper preferably) to be half filled with water 

by monitor. 

3. One or two large pitchers of water, each in charge of a monitor 

who half fills the cups. 



•Suggested by the Committee on Public Health and Education of the 
Second District Dental Society, Brooklyn, N. Y., from whom additional 
copies may be obtainable. 



Fig. 51. 



CHAPTER VIII. 

TUBERCULOSIS AND THE ORAL HYGIENE 
MOVEMENT. 

As has been pointed out again and again one of the 
greatest fields of dental work is that of preventive dentistry; 
from the present trend of medical science, it appears that an 
important branch of this work in the future will be that of 
aiding in the fight on the "Great White Plague." Observa- 
tions have shown me that the vast majority of patients who 
have contracted tuberculosis, have unclean mouths, and, on 
the other hand, I believe the patient with the well-cared-for 
mouth is better able to resist this infection. 

The only successful treatment so far, depends on the use 
of fresh air, plenty of good food, pure water, and rest. The 
most important of these is proper feeding, and proper 
feeding depends on proper mastication. Complete and 
proper mastication can not be accomplished unless the pa- 
tient's mouth is in a healthy condition. Ulcerated teeth, 
flowing pus from pockets, exposed pulps in teeths, and two- 
thirds of the teeth out of the jaw or out of service, will not 
give the proper nutrition even from the purest foods ob- 
tainable. 

The pure air of a pine forest, passing through a septic 
mouth, is no better than the air of a crowded tenement. 

Statistics show that fully seventy per cent, of school chil- 
dren have enlarged glands. This means either a form of 
tuberculosis or else a predisposition towards that disease. 
A large per cent, of these can not have other than dental en- 
trance for these poisons, for most of them have open root 
canals. This has been demonstrated before the German 



146 Practical Oral Hygiene. 

Surgical Society by the process of inoculating the pulps of 
children's teeth. 

In the crusade against the "Great White Plague," there 
is not enough stress being laid on the question of oral sepsis 
as a causative factor for this disease, nor is importance 
enough attached to its worth towards a cure of these pa- 
tients. This matter should be brought to the attention of 
the heads of the various institutions which treat tubercular 
conditions, and also the authorities who control the charity 
institutions. It is our duty to convince these people of the 
great benefits that dentistry can accomplish for those under 
their care. 

A few years ago, the writer became interested in a free 
dental clinic for the "Atlanta Anti-Tuberculosis Associa- 
tion," which was operating a free medical clinic. He brought 
the matter before the Medical Society, and then the Dental 
Society, finally securing the equipment for running the clinic. 
At first the members of the Atlanta Dental Society took up 
the work at stated intervals. At the present time the So- 
ciety has a regular clinician of stated salary to do this work. 
Reports show a great number of filling operations with a 
very small per cent, of oral hygiene treatments. This 
criticism, of course, applies not only to this clinic, but to all 
others of this kind that have come under the writer's inves- 
tigation. Not long ago Dr. Hoff criticised a report of a 
similar case in like manner. I hope that in the future, those 
who have these institutions under management, will bear in 
mind that the stressing of oral hygiene is of more practical 
value than dental restoration to the patients. This is not 
meant to discourage dental work, but it should be, undoubt- 
edly, made secondary, while it is at present primary. Every 
patient who presents for dental attention, should have his 
mouth thoroughly saturated with some antiseptic solution. 
The clinician should not examine the patient's mouth until 
this has been done. Each one of these patients should have 



Tuberculosis and Oral Hygiene. 147 

his teeth cleaned up and treated with Iodine solutions until 
oral sepsis conditions are cured. Not only this, but every 
one of them should be instructed in the use of the tooth 
brush, and made to show improvement in mouth conditions. 
The method adopted in reference to tooth brushes in At- 
lanta is to buy seconds from the tooth brush manufacturers, 
and sell them to the patients at cost. 

In clinics, which I have visited, I noticed that in the medi- 
cal room there are always charts and pictures, showing the 
patients what and how to eat, and how to take care of them- 
selves. In the dental clinic a like method should teach them 
how and why they should keep their mouths clean. It is 
now known that more trouble comes from septic mouths 
than from dental caries. I have frequently noticed that 
these septic mouths do not present as large an amount of 
caries as do mouths under normal conditions. Cards should 
be distributed in the dental clinic, calling attention to the 
importance of this fact, also cards explaining the proper 
use of tooth brush, and dentifrice cream, should be given 
to the patient. If this take all of the time of the clinician, 
then the dental colleges and other clinics of like nature 
would be only too glad to get the regular dental work to 
do. It takes an expert to handle the oral hygiene part of 
the work at this kind of clinic. If our dentists could only 
see the matter in this light, and quit paying all their atten- 
tion to filling teeth, I believe that the medical men would 
soon rally to the cause and place in every institution dentists 
to do this kind of work. While there are medical authori- 
ties who recognize, to the fullest extent, the importance of 
this matter, not until it is generally recognized will the con- 
dition .improve as it should. 

Drs. Weidmann and Lubowski say: 

"There is no disease in which healthy and clean condi- 
tions of the mouth are of such vital importance as in tuber- 
culosis of the lungs. Tubercle bacilli are found in carious 



148 Practical Oral Hygiene. 

cavities, and it has been proved that especially unclean por- 
tions of the mouth constitute a portal of entrance for the 
tubercular poison. Partsch, of Breslau, reports a case of 
grave tuberculosis caused by a carious tooth with such acute 
inflammation of the lymphatic vessels that an operation be- 
came necessary. Also many cases of tuberculous infection 
by way of the alveoli have been reported. These and the 
authors' own observations leave no doubt as to the fact that 
dental caries are responsible for many cases of tuberculosis. 
Tuberculous tumors situated opposite carious teeth resist 
every treatment until the carious teeth are filled or extracted. 
Long-established lymphatic swellings also will generally not 
yield until the carious teeth are treated. All the generous 
efforts of charitable and public institutions for the cure or 
prevention of tuberculosis are of no avail unless the causes 
of the disease are removed, and among the most dangerous 
causes are beyond doubt defective teeth and unhygienic oral 
conditions which exist especially in children." 

S. Adolph Knopf, Professor of Phthisio-Therapy at the 
New York Post Graduate Medical School and Hospital, of 
New York, writes : 

"It must be said to the glory of the American achieve- 
ments that dental science, the art of preserving the teeth by 
truly scientific method, had its birth in this country. While 
we physicians have gone to Europe to complete our educa- 
tion, the European dentist comes to America to learn the 
best and latest in his profession. The latest and most 
glorious development of the American dental science is 
dental hygiene, for dental hygiene means prevention and 
preservation, and these bear the closest relation to the pre- 
vention of tuberculosis. 

"One of the earliest and very frequent symptoms of tuber- 
culosis is impaired digestion. While I do not wish to say 
that bad teeth constitute the only cause of digestive disturb- 
ance, if bad teeth are present, they are a factor contribu- 



Tuberculosis and Oral Hygiene. 149 

ting to this pathogenic condition. Ulcerated teeth may give 
entrance into the bone of tubercle bacilli that have been ac- 
cidentally inhaled or have been contracted by secondary in- 
fection." 

In a later address before the Fourth International Medi- 
cal Congress, held in Washington, Dr. Knopf used even a 
stronger statement: "I defy the most skilled physician to 
either help or cure a tubercular patient who has decayed 
teeth in the mouth." 

Prof. Fisher, of Yale, is authority for the statement that, 
"Seventy-two Americans die every hour from preventable 
diseases." Counting this up for a year, we are amazed 
at the glaring fact of this needless mortality which we have 
here in our country. Enough people might be saved each 
year to populate a city the size of Baltimore, and the further 
fact is that at any time these deaths may come near to our 
own doors. A large per cent, of these deaths come from 
dental origin, and makes it necessary for the dental pro- 
fession to "sit up and take notice." 

Drs. W. G. Ebersole and Marshall have declared that 
decay of the teeth is the most prevalent disease of civiliza- 
tion, and that there are thousands of invalids who are such 
because of faulty oral conditions. They also believe that 
all the medical treatment in Christendom could not cure 
them. It is not for the dental profession nor the medical 
profession to claim the whole field for the work, and, even 
together, we can hardly make a successful fight unless the 
sympathies of the people are gained, and they work with 
us against the great common foe — the "Preventable Dis- 
eases." 



CHAPTER IX. 
BRUSHING THE TEETH. 

SHAPE OF THE BRUSH. TEACHING THE TECHNIQUE OF 

BRUSHING THE TEETH. THE DIRECTION CARD. THE 

CARE OF THE TOOTH BRUSH. THE PROPER USE OF 

THE TOOTH PICK. THE USE OF DENTAL FLOSS 

SILK. THE BAD BREATH SIGNAL. LIME 

WATER AS A MOUTH WASH. 

Tooth brush handles at the present time are made of 
bone, purchased from the Chicago Stock Yards. The best 
grade handles are made from the thigh, and the cheaper 
ones are made from the shin and buttocks bone. The back 
is grooved, holes are drilled, and then wire is drawn 
through, pulling the bristles into place. The grooves are 
then filled with cement. 

The best bristles come from Russia, India, and Ger- 
many. They are washed, bleached, cut into proper size 
selected, and graded. In one tooth brush factory, I am 
informed, some of the graders have been employed for 
twenty years at the same work. 

SHAPE OF BRUSH. 

As to the shape of the brush, we have every variety de- 
scribed, from the sway-back brush to its opposite, the curved 
handled brush in the so-called "Prophylactic Tooth Brush." 
In shape they vary from the largest, as prescribed by Dr. 
D. D. Smith, to the smallest one, described by Dr. Jules J. 
Sarrazin. In texture, they range from the softest brush, 
prescribed by the author, to the stiffest brush, prescribed by 
many of the leaders of the profession. Each dentist has 



Technique of Brushing the Teeth. 151 

some peculiar idea upon the shape and size of the brush, 
but this will have little bearing upon the subject as to clean- 
ing the teeth. 

TEACHING THE TECHNIQUE OF BRUSHING THE 

TEETH. 

There is, however, one point upon which they will all 
agree, and that is the training of the patient into the proper 
brushing of the teeth. It is surprising to note the ignor- 
ance of our best patients upon the handling of the tooth 
brush. It is even more surprising to note how few dentists 
take any time to train these patients. I have made it a 
point to inquire always of new patients whether or not their 
former dentists taught them to use the tooth brush properly. 
Very seldom do they answer in the affirmative. However, 
asking the question, in most cases, is superfluous. The ap- 
pearance of the teeth tells us all that we want to know. 

It is a good idea to have brushes in the office for sale to 
our patients, for, if we give them a prescription, they go 
to the drug store, and do not always get the proper brush, 
and we do not have the chance of teaching them to brush 
the teeth properly. It is a good idea to buy the best brushes 
obtainable by the gross, and allow the office assistant to 
handle the sale of them. Incidentally, there might be added 
all the articles for the proper toilet of the mouth, such as 
floss silk, dentifrice, and mouth wash. People do not buy 
brushes enough. They will use them until they are worn 
almost to the handle. Such a brush is not only laden with 
germs of all kinds, but it is absolutely worse than nothing 
with which to brush the teeth. Such a brush is always shed- 
ding its bristles, which stick between the teeth and cause 
great irritation. 

Dr. C. Edmund Kells was the first man to give me the 
idea of having "Direction Cards" for brushing the teeth, 
for "distribution among the patients when the brush is sold 



152 Practical Oral Hygiene. 

to them." A modification of this card, as used by myself, 
is here shown. If we give the patient these directions orally 
he soon forgets, but if we give them to him on a printed 
card, it is impressed on his mind. (Fig. 53.) 



Directions for the Proper Gare of the Teeth 

Upon RISING the teeth and gums should be most carefully, thoroughly, 
and CORRECTLY BRUSHED— using a soft grade tooth brush and 

After BREAKFAST, waxed floss silk should be passed between the 
teeth (be careful not to snap it down hard upon the gums, as this would 
injure them) or a quill tooth pick should be used — never use a wood 
tooth pick. 

After DINNER or luncheon, when possible, waxed floss silk or a quill 
tooth pick should be used and the mouth most thoroughly washed with 

, , if convenient — otherwise with plain water. 

After SUPPER repeat the above. 

Just before RETIRING, the teeth should be again thoroughly and 

CORRECTLY brushed with and the mouth 

thoroughly rinsed with 

Don't brush across — brush the under teeth up and the lower teeth 
down — brush hard — you can not injure the teeth or gums ; the gums will 
soon become hard, firm and healthy. 

For foul breath nothing equals the pleasant odor, taste, and antiseptic 

qualities of , which should be used in 

good, big mouthfuls and retained as long as possible. Keep the teeth shut 
and alternately distend and draw in the cheeks, forcing the fluid between 
the teeth. 

Nothing short of the above constitutes good care of the teeth. 

(Tack this card above tooth brush holder). 



Fig. 53. A Directiox Card Form Which the Author Gives Each 
Patiext. Ix the Blank Spaces are Writtex the Proper Prep- 
aration? Which are Prescribed for the Patiext. 



Some years ago, I had a patient, an elderly lady, for 
whom I did a great deal of work. When the work was 
finished I explained to her that, at her age, she could not 
expect the work to last as it should unless she brushed her 
teeth properly. At this time, I did not keep brushes for 
sale in the office, and told her to go to the drug store and 
purchase a certain kind of tooth brush and to brush her 
teeth correctly. Some months later, I received a long dis- 
tance telephone message that the work had entirely given 
out, and that her mouth was in a terrible and painful condi- 



Technique of Brushing the Teeth. 153 

tion. An engagement was made. On her arrival, I found 
that the condition was about as she had said. Of course, 
she had been brushing her teeth, "just as you told me, Doc- 
tor." She was rather wrathy. Arrangements were made 
for the patient to come next day, and bring her brush with 
her. The next day she returned, and I had her to brush 
her teeth for me. She brushed the teeth as well as I or 
anybody else could have done it, but, if she had been taught 
for a month, she could not have evaded more skilfully the 
very places which she needed to brush, that is, the gingival 
margin of the gums. This led me to the valuable idea of 
never saying, "brush the teeth," but rather say, "brush the 
gums," for if they brush the gums in a proper manner, the 
teeth will get a thorough brushing. 

In demonstrating the brushing to the patient, there are 
several methods which may be employed. The one advo- 
cated and used by Dr. Edmund Kells and Dr. R. B. Adair 
is that of having a full artificial denture, and demonstrat- 
ing to the patient by brushing this model. However, I find 
it more efficient to have the patient hold a hand mirror, and 
watch me brush his own teeth in the proper manner. A 
peculiar fact is, however, that, while you are brushing the 
patient's teeth, and trying to show him what you are doing, 
his eyes are over the edge of the glass or off to one side, any- 
where except on the mirror. You will have to look in the 
glass as well as at the teeth. They will tell you, "Yes, I 
understand, I see," when they are not seeing at all. Be 
careful about this point, and make them see. When you 
have finished the demonstration, give them a brush, and 
make them go over it themselves. I sometimes have the 
patient hold the brush while I grasp their fingers in order 
to make them go through the proper manipulations. 

I remember one patient, a prominent physician in an ad- 
joining state, whom I had remain for a week, visiting my 
office daily, taking some six or seven lessons before he had 



154 Practical Oral Hygiene. 

mastered the technique of brushing his teeth. It is a la- 
mentable fact that so few people possess enough manual 
dexterity to touch all the surfaces of their teeth. 

Personally, I believe in a soft grade of tooth brush, for 
the reason that the gums are massaged with the sides of the 
bristles; should this be done with a stiff bristle brush, it 
would do considerable damage, that is, if the patient carried 
out my instructions. Again, I know that a soft bristle brush 
is sufficient to clean and polish the surfaces of the teeth. I 
know that whenever I want to polish anything on my lathe, 
I use wheels of fine texture, and, that whenever I want to 
grind or cut into the surface, I use a stiff brush. In the 
mouth I have but one idea, and that is to clean and polish, 
and not injure any structure. 

I demonstrated in my office to several dentists — advocates 
of the hard tooth brush — by cleaning the teeth of a patient 
in the following manner: on one side, I cleaned with a soft 
grade of brush, while on the other side I used a medium 
stiff brush. The debris was cleaned off, if anything, better 
on the side where the camel's hair brush was used, and, on 
the side where the stiff brush was used, the gums were in a 
bleeding condition. 

Dr. Arthur Black says: "I have seen very few cases only 
two of which I have made definite record, in which the gum 
septa have been inflamed by the use of a too stiff tooth- 
brush. In both cases, there was marked improvement 
promptly following the change to a softer brush." 

Dr. M. H. Fletcher insisted that his patients use a -hard 
brush, and, in addition, that the teeth be scrubbed, claiming 
that in addition to cleansing the teeth, the connective tissue 
is developed to a high degree in them. This, he says, has 
the same effect on the teeth and gums as the mastication of 
hay, twigs, and rough food has on the gums of animals. 
Dr. Fletcher also objected to dentifrices that contain soap, 
claiming that they cause the tooth brush to slip over the tar- 



The Direction Card. 155 

tar and food without removing them. On the contrary, 
Dr. N. S. Jenkins claims that this is the most important 
thing for a properly prepared dentifrice. 

It is reasonable to believe that before the deposit of tartar 
takes place, there must be some cementing substance to hold 
it in place — some agglutinizing material; thus, if we fail 
to brush our teeth one day, this material accumulates on the 
teeth, and forms the beginning of calcarious deposits, with 
the result that from this one day's lack of brushing a rough 
surface is left for the beginning of an accumulation. We 
see how important it is to train our patients to know that an 
irregular system of brushing the teeth fails, and that for 
brushing the teeth, to be successful, it must be regular and 
systematic, with no skips in between. After the material 
has accumulated on the teeth for a few days, it is impossible 
for the patient to remove the deposits, and he must report 
to the dentist. 

Dr. Francis says, "Some mouths, so far as the tooth brush 
is concerned, are unexplored caverns of miniature type, and, 
others, which receive an occasional visit from the intrusive 
explorer, are not in a very much better condition for the 
little care bestowed upon them." 

Expressions as the one just cited should urge us to the 
utmost to bring about a change of thought in the minds of 
our patients toward the cleanliness of their mouths. This 
training of patients to brush their teeth properly is one of 
the hardest and most thankless things that the dentist has 
to do. 

THE DIRECTION CARD. 

In former years, before I used the printed "direction 
cards," much time was spent in training the patients. When 
at a subsequent sitting, if asked to demonstrate how they 
were brushing their teeth, they would do almost the oppo- 



156 Practical Oral Hygiene. 

site from what had been told them. The patients often 
replied with the expression, "Now, that is just the way you 
told me." 

Now, after training the patients, a card containing con- 
densed directions for the care of their teeth is given. They 
are requested to preserve this card. The patients will get 
a better idea from seeing the suggestion in print. Then 
when they claim, "just as you showed me," you have all the 
advantage by using another direction card. All dentists 
should have printed some card giving their directions. It 
saves time, does good, and costs little. 

On the direction card illustrated, note carefully the word 
"Correctly," and the technique which is given; if this is 
carried out it will remove the debris from the teeth, and give 
a better massage effect to the gums than any other method 
with which I have experimented. This results in the bristles 
going into the interstitial spaces. 

The manner in which most people brush their teeth re- 
sembles the way in which the small boy shines his shoes on 
Sunday morning. He shines the tips all right, but, if left 
to himself, he never touches the heels. People will brush 
their front teeth, but they never get to the back ones. 

In brushing the teeth, we should begin at some definite 
point, such as, for example, the upper right buccal surfaces. 
The brush is placed with the bristles pointing straight up, 
the side of the brush against the gums. A rotary tilting 
motion revolves the bristles, using the hand as an axis, and 
thus forcing the bristles between the teeth. The brush is 
next moved around to the front, and then the left buccal 
surfaces. Then, in order, brush the palatal and lingual 
sides of the teeth with the same position of the brush, high 
upon the arch, and turned outwards, bringing the bristles 
down between the teeth. Then the occlusal surface of the 
molar teeth is given careful attention. 



The Direction Card. 



i57 



CLEANING THE 
x |N5IDE0f 
N THE LOWER. 
FK0NT TEETN 




Fig. 54. Showing Important Tooth Brush Movements. 



158 Practical Oral Hygiene. 

Dr. Fones states that the tooth brush be made to travel 
as fast as the hand can be made to go, and he gives another 
useful point in brushing the inner surfaces of the lower teeth, 
which is, to have the patient hold the thumb on the top of 
the handle instead of around it. 

The brush is now placed in the right side in just the re- 
verse manner. On the lower jaw, it is just the reverse as 
on the upper. Here, the bristles point straight down, and 
the long side of the brush is against the gums. We now 
bring pressure, and rotate the brush upwards. The same 
technique is brought out around the circle of the teeth, but 
when we come to the lingual sides of the lower jaw teeth, 
we have to change our technique. Here, the brush has to 
be pressed between the -tongue and the molar teeth. The 
molars should be brushed with an in and out movement, as 
the rotary movement would be of no use on account of not 
being able to get the brush below the gum margin. The 
lingual surfaces of the lower incisors is brushed by inserting 
the brush as far down as possible, and bringing it out with 
an upward movement. We must caution the patient against 
brushing across the cuspids for fear they will cut grooves. 
We mean when we say, "A clean tooth will not decay," that 
the pabulum on which germ life will feed has been removed, 
or rendered inert. 

Every dentist seems to have some special shape and va- 
riety of tooth brush. The brush advocated by Dr. A. E. 
Peck has recently been given a personal trial by the author 
with the results so satisfactory that he gives an illustration 
of its shape and a copy of the directions which Dr. Peck 
says, "is a new method of cleaning the teeth with the brush 
which will entirely eliminate the danger of causing the gums 
to bleed, and in this way, the possibility of infecting the 
whole system." 



The Direction Card. 



i59 







Fig. 55. The Peck Method of Brushing the Teeth. 



The cross-sectional drawings show the proper positions of the brush 
while cleaning the outside of the lower back teeth. 

Always start with the back teeth. Force the brush down between 
the gums and cheek until the back of the brush rests on the edge of 
the gums at the angle shown in Cut No. 1. 

The brush should then be rotated (about Y% turn) to the position 
shown in Cut No. 2, with the sides of the bristles pressed firmly 
against the gums. Next raise the brush to the chewing surface of 
the teeth, keeping the bristles at the angle shown in Cuts No. 2 and 3. 
Repeat this movement until the teeth are cleaned. 

To avoid injury to the gums in brushing the outside of the front 
teeth, place the brush in the back part of mouth as shown in Cut No. 
1 and then draw it forward to the teeth to be cleaned, keeping the 
bristles well under the lip. The back of the brush should now be in 
the same relation to the gums of the front teeth as shown in Cut No. 
1. Then finish the operation as shown by Cuts No. 2 and 3. Re- 
peat this movement until the teeth are thoroughlv cleaned. 



160 Practical Oral Hygiene. 

In cleaning the inside surfaces of the lower teeth, start with the 
ends of the bristles pressed against the tongue. Finish as shown in 
Cuts No. 2 and 3. 

To clean the inside of the upper teeth place the side of the bristles 
against the roof of the mouth and gradually rotate the brush about % 
turn while you are drawing it to the chewing surface. 

In cleaning the inside surfaces the entire brush must always remain 
inside the teeth. Never let a part of the bristles come over the ends 
of the teeth. 

THE WRONG WAY. 

Never rotate the brush so the ends of the bristles rub against the 
gums as shown in Cut No. 4. This is liable to cause bleeding and 
infection from dangerous germs which may be on the ends of the 
bristles. 

Impress them with the importance of removing all deposits of food 
or other material which would form a good culture ground for dan- 
gerous germs. These deposits under the margin of the gums can be 
removed by the patient with a properly shaped stick and an abrasive. 

The Tongue Scraper, Massage Stick, and Polish will assist mate- 
rially in this work. With this stick they can keep the tobacco stains 
from their teeth, and prevent many plaques from forming. The 
mother can use this stick on the teeth of the children who are too 




Fig. 56. The Cake of the Tongue is Often Neglected. Some Simple 

Appliance as Above, Pboperly Used, is a Great Aid 

Towards a Clean Mouth. 



The Direction Card. 161 

young to come to the dentist. She can help keep their mouths clean 
and healthy, and at the same time educate them to the importance of 
having their teeth attended to. It will familiarize them with having 
others work on their teeth, and when they do come to the dentist they 
will be much more easily handled, and better results will be obtained. 
The value of the tongue scraper was recognized by the Chinese 
many years ago, and a jeweled tongue spoon was a part of their toilet 
requisites. The removal of the disintegrated mucus from between 
the papillae of the tongue eliminates from the body a fine culture 
ground for all kinds of bacteria. The tongue scraper should be used 
soon after rising each morning. 

Dr. Paul R. Stillman is a strong advocate of the dentist 
taking time to teach his patients the proper method of 
brushing the teeth. In the following quotation is given his 
views on the question. 

"I wish first of all to condemn the whisk-broom method, 
or so-called sweeping of the teeth, as taught by certain oral 
hygienists, who lecture before Mothers Clubs, school chil- 
dren, etc. It is not my intention to cast reflection on the 
splendid work done for oral hygiene in general by these men, 
but their teaching of technique on the subject of the tooth 
brush is both incorrect and inefficient. 

"If I wished to clean the floor of a street car, I wouldn't 
sweep it at all. I would get a pail of hot water, soap and a 
scrubbing brush and I would scrub the floor of the car, and 
after I had scrubbed it I would rinse it clean. We see too 
many mouths every day that are swept, and they compare 
with a clean mouth about as a swept car does with a scrub- 
bed one. 

"This sweeping method of using the tooth brush was 
genuinely and earnestly advocated by men seeking a better 
way than the harmful practice that is still almost universally 
used by the uninstructed. I refer to the violent mesio-distal 
stroke similar to that used by the boot-black in his work. 

"We have all observed mouths which show the pernicious 
effect of this habit. The method is actually harmful. 

"The brushes I prescribe are always small in size. Small 
brushes are more efficient for they will reach surfaces that 



162 Practical Oral Hygiene. 

the ordinary size can not. Usually those sold as 'child's 
size' for adults, but frequently in mouths of mal-occlusion 
I prescribe the still smaller size. In rare cases when the 
lower teeth incline lingually, or where certain individual 
teeth are out of arch alignment, the ordinary type of tooth 
brush is not sufficiently efficient and I supplement with a 
porte polisher in which small brushes may be inserted. 

"Try this little experiment: Take a little flour of silex, 
plaster of paris or tooth powder, and rub it upon the thumb 
nail and well into the cuticle. Now take a tooth brush, 
laying the bristles flat, and with the same revolving-on-its- 
axis movement of the brush, as described in the whisk-broom 
method of sweeping the teeth, sweep the powder toward the 
end of the nail. You can not clean that powder from the 
nail in fifty sweeps. If this experience does not convince 
you, use a brush on the next patient's mouth, and see how 
impossible it is to clean the gingival border and the adjacent 
tooth surface with the whisk-broom technique." 

THE CARE OF THE TOOTH BRUSH. 

The tooth brush used by a person having a healthy mouth 
will show millions of organisms. If the bacterial count be 
made from a brush used by a person having a considerable 
amount of oral sepsis, we will find more micro-organisms 
than in common sewage. 

The ordinary cleansing of the tooth brush is without ef- 
fect. On the other hand, we are at a loss to know how to 
advise patients in regard to the proper sterilization of their 
brushes because any really effective agent will destroy either 
the bristles or the handle of the brush. 

German experiments have shown that those brushes which 
are used in combination with some dentifrice having anti- 
septic properties carry a smaller number of bacteria than 
others. 



The Care of the Tooth Brush. 163 

Efforts have been made to provide a small sterilizer for 
individual brushes, but these, so far, have proved a failure. 
Some of them used formaldehyde gas which proved so dis- 
agreeable on the brush that the individual would not use it. 

All-glass cases for keeping brushes become counter-in- 
fected. Brushes are kept best where fresh air and, if pos- 
sible, where sunlight can get to them. 




Fig. 57. Many of the dentists' best patients are using brushes like 
this constantly. This one was being used by a lady of the highest type. 
The cut fails to show the covering of scum. No matter how much talk 
and treatment you give the patients, if they use a brush until it gets 
into this shape their gums will continue to be infected. (From author's 
collection.) 



To prevent the tooth brush from becoming a culture me- 
dium, we should first advise the patient to have regular, 
systematic cleansing of the mouth to keep the bacterial con- 
tents therein normal. Every time the dentist cleans a pa- 
tient's teeth, the purchase of a new brush should be insisted 
upon. Generally, we are met with the remark: "I just 
bought one a week ago." The patient, not knowing the 
importance of this matter, will generally tell you that the 
brush is in good condition. The suggestion is offered that 



164 Practical Oral Hygiene. 

the dentist at each cleaning furnish a new brush to the pa- 
tient with his name engraved on the handle by means of a 
dental bur and blackened with ink. At each engagement 
for tooth cleaning, insist that the patient bring the brush 
which he has been using at home. Often, even though the 
cleanings have been six months apart, the same old brush 
will be handed you. Often only a handle is brought, some- 
times filth fills the spaces between the tufts of the bristles. 
(Fig. 57-) 

The use of the tooth brush has been looked on as one of 
the signs of high civilization, but of late, the bacteriologists 
have said so many bad things about it that unless we can 
keep it clean it would be better for civilized man to use 
other means of cleaning his teeth. 

Sometimes by telling a story of the extreme side of the 
question, we can impress the patient much better with the 
thought which we wish to bring out. The following may 
be used to good advantage. 

One patient told the dentist not to advise her husband 
to brush his teeth for when he went to a dentist a day or 
two he became so interested in his brushing that he often 
used her brush as he could not find his own, since he had no 
regular place to keep it. 

A prosperous farmer brought his daughter to a dentist 
and, on being told the need of brushing the teeth asked the 
price of a good brush. 'Til take one," said the old fellow. 
But on being informed that he needed one for each member 
of his family, he made the following reply: "One is enough 
for all of them until I see whether it works as well as you 
say it does." One was all he could be persuaded to take. 

Mrs. Ganung, of the Fones school, reports the following 
incident: "I asked one of my little patients one day if he had 
his tooth brush with him, whereupon he produced from his 



Proper Use of the Tooth Pick. 165 

pocket a rather hard-looking brush, well worn and far from 
clean. I started giving him instructions in brushing, while 
his brush was soaking. His conscience apparently bothered 
him, for he finally stammered: 'Eh! that isn't my brush, it's 
my uncle's, but he lets me use it!' He was given a new 
brush for his exclusive use upon the promise that he would 
keep it as his personal property." 

THE PROPER USE OF THE TOOTH PICK. 

Tooth picks certainly injure the gum structure, still their 
non-use at the proper time causes still greater harm, so all 
we can do is to advise and caution our patients against the 
resultant dangers if not properly used. Some of the most 
painful cases I have ever relieved were caused by points and 
splinters from wood tooth picks broken off between the 
teeth or stuck into the gum structure. Advise against the 
wood pick. 

The small size quill tooth pick is the best to use. Before 
using, the sharp point should be snipped off with scissors or 
a piece of sandpaper. 

When food is impacted between the teeth, the pick must 
be used to get it out, but it must not be jammed into the 
gums or interproximal spaces. I have heard patients say 
that they use a pick every day until the gums bleed. When 
the gums do bleed, it is a sure sign that the patient has stab- 
bed or lacerated the gums, causing an inflammation which 
may develop into a Pyorrhea pocket for the further lodg- 
ment of debris and pathogenic bacteria. 

The dentist may not think it his business to go into detail 
with his patient about such a little thing as the use of a tooth 
pick, yet the patients have to use them, and their abuse 
causes such serious results that it behooves us to give the 
proper instruction. 



1 66 Practical Oral Hygiene. 

THE USE OF DENTAL FLOSS SILK. 

Every article used to obtain a clean mouth is subject to 
abuse. We have mentioned a few due to the brush and 
tooth pick. Floss silk is not free from this possibility. 

I would rather a patient would neglect the brushing than 
the use of silk, yet, one is just as important as the other. 
Few patients seem to possess the manual dexterity to use 
the floss silk properly. If the dentist be content merely to 
suggest to the patient that he use the silk serious injury to 
the gums and the peridental structure is sure to result. 

The floss should not be snapped between the teeth. It 
should not be given a violent saw motion. It should be 
withdrawn buccally or lingually, as this prevents the break- 
ing of the silk and more readily cleanses these surfaces. For 
those patients wearing bridgework, the dentist can furnish 
an instrument to thread the floss under the work. This in- 
strument is made of small size aluminum wire, the loop end 
being bent about an inch, forming an eye through which the 
silk is threaded and carried under the bridge. The other 
end of the instrument can be formed into a larger loop and 
flattened to use as a tongue scraper. Instruct the patient to 
saturate the strand of floss silk with tooth paste. This 
cleanses better and exerts some antiseptic properties. 

If the teeth are open enough for the use of flat silk, this 
grade is preferable for the reason that it cleanses better and 
more quickly, also there is less danger of injury to the soft 
structures. 

The patient should be taught that he is using the floss silk 
to remove particles between the teeth and not to force them 
under the gums. If they will give the proper attention to 
what they are doing when using silk, they will soon be able 
to distinguish the difference in feeling when the silk is prop- 
erly used. 

The patient must also be instructed to return for examina- 
tion when he finds that the silk cuts or breaks when used be- 



Use of Dental Floss Silk. 167 

tween the teeth, for this means some decay has taken place, 
or that calculus or some overhanging edge of filling should 
be looked after before the decay gets of much size, or the 
filling or crown be pulled out. 

Dr. Grace Rogers Spalding is a great believer in the use 
of dental floss. To emphasize the importance of its use, 
she presents her patients with neatly printed cards, two of 
which are here illustrated. (Figs. 58 and 59.) 



With Apologies to "Life" 

THERE ARE BETTER THINGS TO REMEMBER 
THAN BRUSHING ONE'S TEETH, BUT ONLY ONE 
THING WORSE TO FORGET— DENTAL FLOSS. 



Fig. 58. Printed ox Best Grade Card Board, Size 5x3. (Spalding.) 



FOUR REASONS FOR USING DENTAL FLOSS 

i. There are 64 surfaces of a complete set of teeth which 
the tooth brush can not reach. 

2. More cavities form on these surfaces than on any 
others, which can to a large extent be prevented by the 
intelligent and systematic use of the proper kind of dental 
floss for breaking up bacterial plaques, the cause of dental 
caries. 

3. Food particles forced between the teeth undergo 
chemical change in a few hours at the temperature in the 
mouth. The dental floss can remove them completely. 

4. Anyone wearing a fixed bridge needs to use dental 
floss to care for it properly. 

Dental floss to be effective must have width so that it 
can be used to polish the proximal surfaces of the teeth. 
If by correct manipulation you can not get it between all 
of your teeth there is something needing attention. Im- 
proper use of the dental floss may produce injury to the 
soft tissues; so use it carefully and intelligently or not at 
all. 



Fig. 59. Printed on Card, Size 5x3. (Spalding.) 



i68 



Practical Oral Hygiene. 



Dr. Kells says: "I have concluded that the only way to 
cleanse the teeth, especially when there are pockets of any 
description, is by a flushing machine. I believe I can take 
any mouth after it has been flossed and brushed and work 
debris out of any pocket with a fine stream. No hope can 
be entertained that patients will use the method, but the 
facts stated will hold nevertheless." 

For this flushing he furnishes his special patients with an 
outfit made from the metal point of a chip blower having 
about five feet of small tubing attached, the opposite end of 
which is fitted with a suitable cork for inserting into the 
water faucet of the bath-tub. (Fig. 60.) 




Fig. 60. Dr. Kells' Idea of Flushing the Mouth. Made of Chip- 
Blower Nozzle. Small Tubing and Cork, End of Which 
is Inserted Into Water Faucet. 



The author fully agrees with the idea, but believes his 
method is more practical and will be carried out by the 
patient. In cases where the patient has pockets, either of 
gum or bridge-work, it has been his custom to furnish a 
Moffett water syringe and to give instructions for its use. 



The Bad Breath Signal. 169 

THE BAD BREATH SIGNAL. 

How often on the street corner, on the car, in the church 
pew, at the social function, and in the dental chair have we 
been annoyed by having to associate with those individuals 
who suffer from bad breath. As the possessor of the bad 
breath is not aware of its odor, he, consequently, does not 
know that he is so afflicted, and it does seem that he always 
wants to get up close to your face to talk. Strange to say, 
some of these very people carry out to the best of their 
ability and knowledge the ordinary rules of mouth hygiene, 
and yet this condition continues to exist. 

This is a very delicate matter to mention, and yet, there 
is no one so well placed as the dentist to help in this re- 
spect. The subject of foul breath should not be discussed 
with these patients, for they are very sensitive on the sub- 
ject. However, in a tactful manner of speech, we can train 
them into a more accurate system of flossing the teeth, and 
can suggest their taking up a system of Prophylaxis. If 
we do this, we can work out to our satisfaction the cure of 
this defect. 

Dr. Geo. M. Niles, a Gastro-Intestinal specialist, has 
written a valuable paper on the subject of "The Bad 
Breath: What it Portends." Some extracts from this 
paper give us valuable information on this subject. 

"When the personal odor is offensive, it is a great misfortune; if 
preventable, it is an inexcusable disgrace. 

"In the ordinary intercourse between individuals, the exhaled 
breath generally constitutes the most noticeable odor, and it is to 
that phase of the subject this study is mainly directed. 

"Every one of my readers can probably call to mind one or more 
acquaintances, who, except for an abominable breath, would be attrac- 
tive; but from the presence of this handicap, are avoided, perhaps dis- 
liked. 

"A busy dental surgeon, of this city, who has offices in the same 
building with a rectal specialist, recently informed me that, on com- 
paring notes, they both decided that the dentist, in his daily routine, 
encountered more offensive and septic cavities than did the latter in 
his rectal work. 



170 Practical Oral Hygiene. 

"The mouth, as the portal of entry for food and air, warm and 
moist, with numerous nooks and crannies, where stray particles of 
food and other debris may furnish an inviting field for countless micro- 
organisms, is by far the most fruitful source of bad breath. Among 
other causes in and adjoining the mouth, besides carious teeth, pyor- 
rhea alveolaris, tartar, septic gums, glossitis or stomatitis, may be men- 
tioned necrosis of the nasal bones, purulent hypertrophic or atrophic 
rhinitis, ozena, septic tonsilitis, or even squamous-celled carcinoma of 
the mouth or tongue. 

"After all is said, however, it must be admitted that we occasionally 
see a patient in whom no adequate cause can be found, but w T ho, never- 
theless, labors under this misfortune. Though it is possible that such 
may be due to some lamentable personal idiosyncrasy, w T e should be 
slow to admit such a contingency. In these rare cases a persistent 
search will sometimes disclose a putrefying impaction in some almost 
inaccessible recess in the mouth, where neither tooth brush nor denti- 
frice can penetrate. A dentist of experience of this city, stated to me 
that a breath of surprising foulness could be produced by one small 
impaction of this sort — so small as to be discovered only after patient 
search. 

"Successful management by the physician or dental surgeon will 
afford such relief from embarrassment to the patient and annoyance 
to friends, that well may the emancipated sufferers 'rise up and call 
him blessed.' " 

While most cases of foul breath are due to mouth condi- 
tions of the patients, it may come in some degree from con- 
stipation or intestinal intoxication. Generally, in uncom- 
plicated cases, the taking of some purgative medicine, as one 
teaspoonful of epsom salt before breakfast, for a week 
or ten days together with larger quantity of water, will help 
this condition. 

LIME WATER AS A MOUTH WASH. 

The number, kinds, and styles of dentifrice and mouth 
wash formulae are legion. It is not the intention of the 
writer to enter into a discussion of their relative merits, ex- 
cept to say that it is not so much which brand is used as 
the way in which it is used. 

As many of our prominent dentists have become such 
strong advocates of the use of lime water for a mouth wash, 
the method of its preparation will be given. 



Lime Water as a Mouth Wash. 171 

Dr. Kells was one of the first advocates of lime water as 
a mouth wash. As the proper quality of lime is rather 
hard for the patients to secure, he keeps this put up in two- 
ounce bottles for supplying his patients. His idea is that 
if the patient uses a proprietary mouth wash in as large 
quantities as he prescribes, it would be too expensive for 
them. 

Noticing that Dr. Fones, of Bridgeport, Connecticut, also 
recommends lime water, I asked him to give his opinion 
relative to the recent publication of Pickerill, who claims 
that all alkaline mouth washes prevent a free flow of saliva, 
and, as the saliva is the best mouth wash possible, the use 
of lime water does not have the desired effect. My per- 
sonal experience was that it always left a furred feeling in- 
stead of a cleanly one. 

In answer to these queries, Dr. Fones wrote me, and I 
quote at length : 

"The reason why I am such an advocate of lime water for 
a mouth wash is that it is such a powerful, yet harmful, sol- 
vent for the mucilagenous accumulations around the necks 
of the teeth, as well as their proximal surfaces. 

"Kirk has found by scientific experiments that it is one of 
the best solvents for plaques and gummy accretions of the 
teeth that has come under his observation. Its alkaline re- 
actions does not especially enter into the subject in consid- 
eration of its merit. If you will secure the coarse lime, 
which is a very light cream color, and prepare it in the fol- 
lowing manner, I am sure you will not have any furry effect 
in your mouth, but one of extreme cleanliness. 

"Place a half cup of the unslacked lime in an empty quart 
bottle, and then fill with cold water. Thoroughly shake and 
allow the lime to settle. Pour down the sink all the water 
you can without losing any of the lime, as this first mixture 
contains the washings of the lime. Again fill with cold 
water and shake, and when this has settled pour off some of 



172 Practical Oral Hygiene. 

the clear water in a ten or twelve ounce bottle for use at 
the bowl and again fill the quart bottle with cold water, 
shake and set aside for future use. This operation may be 
repeated until five or six quarts of the mouth wash has been 
used. If the lime water is a trifle strong at the start, dilute 
that in the small bottle with water. After rinsing the mouth 
with the lime water (and the rinsing should be of sufficient 
length of time to thoroughly foam it), rinse the mouth with 
clear warm water. I have yet to find anything to beat it." 



CHAPTER X. 
CLEANING THE TEETH. 

SKILL REQUIRED FOR THE WORK. THE BEST TIME TO CLEAN 

THE PATIENT'S TEETH. THE USE OF A DISCLOSING 

SOLUTION. INSTRUMENTS USED FOR CLEANING 

THE TEETH. ABRASIVE MIXTURES USED IN 

CLEANING THE TEETH. 

Under the term, "Cleaning the Teeth," will be described 
the operative measures employed at the dental chair for 
removing deposits, bacterial plaques, and stains from the 
average mouth. This term does not give sufficient dignity 
to the work and all investigators who work along this line 
will be glad for a better term. None has been forthcom- 
ing and, as all our patients know what we mean when we 
use this term, it is one which we will more often be forced 
to use with them. If our clientele understand "Removing 
Infection," or "Prophylaxis," then these terms may be em- 
ployed. 

It seems rather a strange coincidence that a few years 
ago the dentist who "cleaned teeth" was in danger of losing 
his club and social standing, but within the last few years 
the importance of this procedure has so impressed itself 
upon the patients that the man who does not clean the teeth 
of his patients, or have it done, is looked upon as a dentist 
who neglects his legitimate duty to his patients. There 
was a time when our profession would put in beautiful fill- 
ings and send the patients away with a clean bill of health 
although the free margin of the gums exhibited rings of 
calcareous deposits. It was not many years ago that the 
patient would not pay, or rather was not required to pay, 



174 Practical Oral Hygiene. 

more than from one to three dollars for this operative pro- 
cedure. Many of the laity were accustomed to having, as 
the Indians express it, the cleaning put in as "potlash," that 
is, where any work was done, the cleaning was added free 
of charge. In view of this state of affairs it is not to be 
wondered at that there was so little cleaning of the teeth 
done by the dentists. It was also a deplorable fact that 
our colleges paid little heed to this subject and many grad- 
uates, during their college days, never saw a mouth prop- 
erly cleaned up by their professor or demonstrator. If the 
college did any of this work it was relegated to the fresh- 
men. 

SKILL REQUIRED FOR THIS WORK. 

From the belief that any one can clean a set of teeth we 
are now learning that this operation requires most expert 
ability and thorough knowledge of anatomical landmarks, 
as well as medical treatment for pathological conditions. 
Generally the placing of fillings is mere routine work but 
the more teeth we clean, and the more mouths we put in a 
healthy condition, the more we realize that greater skill 
is required here than in any other line of work which we 
do. We have learned that the average patient can not 
maintain clean teeth, and that he will be compelled to have 
our professional assistance along this line. We have also 
learned that this work is of immense value to the patients, 
and that it is worthy of a reasonable compensation which 
will enable us to pay more attention to the matter. 

To secure a clean set of teeth — one that would be so con- 
sidered by a specialist in prophylaxis — is one of the most 
difficult procedures in dentistry. It behooves us to put just 
as much time on this work as practicable, or, in the event 
the patient is one who will appreciate this service, as much 
time should be given him as would accomplish the proper 
cleansing of the teeth. 



The Best Time to Clean Teeth. 175 

THE BEST TIME TO CLEAN THE PATIENT'S TEETH. 

A surgeon would not dare perform any operation with- 
out first making some attempts at cleaning and sterilizing 
the field of operation, but the dental surgeons absolutely 
ignore these rules of surgical procedure. I do not think 
that any dental operation should be undertaken until the 
teeth have first been properly cleaned. This should be done 
as routine work. There are many advantages resultant 
from this procedure. In the first place, it puts the clean- 
ing operation on a higher plane than if it were done when 
the regular dental work is finished. In the second place, it 
enables us to bring forward the salient points of oral hy- 
giene to the patients. In the third place, it protects the 
dentist from any infection, should any of these germs be 
absorbed through a break of the skin in his hands. In the 
fourth place, it prevents him from having the possible in- 
fection of hay fever, la grippe, and tuberculosis, for, if the 
mouth be properly cleaned out, the danger of infection from 
this source will be reduced to a minimum. In the fifth 
place, there is no doubt in my mind that if the mouth is 
properly cleaned out before the work is done, crowns and 
bridges will stay and last longer. There are many other 
reasons that I could enumerate, but these are enough to 
impress the matter on the mind of the dentist. Again, I 
would like to repeat, "Clean or have cleaned every set of 
teeth before you operate." 

Right here comes the question, "Who shall do this work?" 
Some of us have dental nurses in our offices, and to them is 
intrusted this work. I have seen better work done along 
this line by them than by many dentists. If you can train 
an assistant to do this work, well and good. 

The methods employed in cleaning the teeth are many 
and varied. Whatever method is employed, let us be sure 
that the patient's gums and lips are not torn up with the 
instruments or the floss silk. All of us have seen patients 



176 Practical Oral Hygiene. 

with their mouths so sore that they could not brush their 
teeth for a day or two, or even chew their food properly, 
following the simple operation of cleaning. There is no 
need for any great physical force to be exerted in the opera- 
tion. 

THE USE OF A DISCLOSING SOLUTION. 

In beginning, it is well to spray the mouth with a solution 
containing aromatic spirits of ammonia, diluted three times 
with water. This removes the viscosity of the saliva, and 
removes all decomposed particles of food. It is a strong 
cleanser, and has a pleasant effect. We now paint the teeth 
with some staining solution, the best of which is Skinners' 
Disclosing Solution. 

FORMULA FOR I OZ. DISCLOSING SOLUTION. 

Iodine (crystals) grs. 50 

Potassium Iodide grs. 15 

Zinc Iodide grs. 15 

Glycerin drs. 4 

Aqua drs. 4 

Mix. Sig. paint teeth (one or two at 
a time) and rinse immediately with 
water. 

Put up in glass stopper bottle. 

In making it, put the iodine, zinc, and potassium iodide 
into a mortar with five or ten drops of glycerin. Grind to 
a thick syrup, and then pour all you can into the bottle. 
Pour the remaining glycerin into the mortar, and stir with a 
pestile. Pour out again, then add water, and stir again. In 
this way you can get all the solids out of the mortar, whereas 
if the solids and liquids were all put in at once, some of the 
iodine would stick to the mortar, and an inferior staining 
solution would be the result. This solution shows up the 
bacterial plaques and aids in removing them. 



Instruments Used for Cleaning Teeth. 177 

INSTRUMENTS USED FOR CLEANING TEETH. 

There are many and varied instruments on the market 
for removing calculus, and with most of them you can ob- 
tain good results. It is a question of personal equasion. I 
would caution you to select, and use the smaller instruments. 
Many colleges have on their required instrument list scalers 
which suggest plows rather than dental instruments. The 
writer has for years been an advocate of the Good-Younger 
instruments for this work, for the reason that they can be 
used either "push" or "pull," and, being small and rounded 
on the back, do not injure the tissue; there are rights and 
lefts and can be used in a double ended handle, simplifying 
operating a great deal. 

The students should be taught that pyorrhea work is on 
the same principle as cleaning the teeth, and, if they hope 
to operate for pyorrhea, they must become adept in clean- 
ing teeth. With this thought in view, let me urge that much 
care be taken in the use of whatever instruments are selected 
for this work. 

It takes a separate set of instruments for this work, and 
for the pyorrhea work, for here we do not wish the instru- 
ments to be sharp. It is advisable to round off the sharp 
edges of the set intended for cleaning the teeth. Much in- 
jury can be done to the peridental membrance if its attach- 
ment is separated at the gingival border. Use a chip 
blower, or a strong current from the compressed air syringe, 
and blow at the gingival margin, thus forcing the margin 
of the gums away. This enables the operator to see the 
small patches of infection or deposit which have been previ- 
ously stained by the solution. The assistant can so manipu- 
late the air syringe as to be of great aid to the operating 
dentist. Now, as in pyorrhea work, to be skillful, one must 
brace his fingers on the teeth, so that no slip of the instru- 
ment can occur. The small blade of an instrument should 
be run completely around the free margin of the gums, for 



178 Practical Oral Hygiene. 

* 

we have found this to be the starting point of many patho- 
logical conditions of the gums. It does no more harm to 
carefully clean out this free margin than it does to clean 
out the finger nails. In fact, one of the tests that I make 
of new instruments is to run them under my thumb nail, 
and, if it cleans the cuticle there without injury, it will do 
to use under the free margin of the gum. 

After the instrumentation has been done, the next proce- 
dure is the use of waxed dental floss silk between the teeth. 
The usual round dental floss will not give the desired re- 
sults. You must have a flat floss to do the work properly. 
It must also be as large as can be forced between the teeth. 
On this floss we use an abrasive consistent with the amount 
of infection which is to be removed. If the spaces between 
the teeth are large, and considerable debris is to be re- 
moved, then we may use an abrasive containing flour of 
pumice. On the other hand, if the patient's mouth is in 
fairly good condition, we need not use such an abrasive 
powder, but use a chalk mixture or one of the formulas 
which I am giving at the end of this chapter. There is one 
caution to be borne in mind, and that is, in using large size 
silk place the thread between the teeth and then place on 
whatever abrasive is to be used. If we placed the abrasive 
between the teeth, and then attempt to pass the silk, we 
would find it almost impossible to do so, and, even if it did 
go, one half of the floss silk would be cut in two. 

It is not necessary to saw the gums or the cheek with the 
silk, nor is it necessary to fill the mouth with the abrasive 
material. The smallest amount is all that is necessary. 
The silk should be passed thoroughly between all the teeth 
and threaded under whatever bridges the patient may wear. 
When this is done, the patient's mouth must be thoroughly 
rinsed out with a syringe, or sprayed with compressed air, 
and then some mild antiseptic mouth wash used. 



Instruments Used for Cleaning Teeth. 179 

We are now ready to cleanse the bodies or the crowns 
of the teeth. If you have the skill, and the time, there is 
no better method than the orange wood stick and dry pumice 
flour, but, while this is the ideal method in prophylaxis, for 
the simple cleansing of the teeth, most of us will use the 
dental engine. There are many and varied devices at our 
command for use on the engine in our hand piece. Possibly, 
you have adopted the bristle brush as being the most effi- 
cient; nothing has yet been found equal to the brush wheel 
for polishing. We should have one right angle hand piece 
set aside for this work. Surely, everybody has an old right 
angle that can be dedicated to this work. I have never been 
able to do this class of work with a straight angle hand 
piece, and any one who has used a right angle for cleaning 
teeth with a bristle brush, will never use a straight one 
again. Formerly, I had a great deal of trouble with my 
right angle in this work, because of the abrasive getting into 
it, but now I use the Consolidated Dental Mfg. Co.'s right 
angle, which completely closes at the back, and by inserting 
a rubber cup on backwards, I can keep the abrasive out of 
the mechanism (Fig. 61.) Needless to say, a fresh brush 
is furnished to every patient. However, I can see no objec- 
tion to these brushes being saved, and, at the end of the 
week, being cleansed by boiling for fifteen or twenty min- 
utes, and used in future operations. 




Fig. 61. 

These inverted bristles can be had in a stiff grade, which 
are black, and in a soft grade, which are white, also in 
camel's hair brushes. The unmounted kind are the ones 



i So Practical Oral Hygiene. 

used in right angle hand piece, using the shortest right angle 
mandrel. 

With the sharpened orange wood stick, place the abrasive 
around the teeth, and with the dental engine running at a 
low rate of speed, carefully go over all surfaces of the teeth 
giving the hand piece a motion from the gum toward the 
cutting or grinding surface of the teeth. The mouth is 
again washed out, and the staining solution applies as at 
first. If there is any debris, bacterial plaques, or calculus 
still remaining, this staining solution will immediately show 
them up. 

Now comes one of the most important parts of the opera- 
tion — the careful removal from under the free margin of 
the gums all trace of the abrasive that has been used. It 
takes force to remove this material, and calls for the high- 
est pressure which we can put on the air or water syringe. 
We must bear in mind that this abrasive has sharp edges, 
and, if left under the gum margin, may cause irritation or 
pyorrheal conditions. The mouth should then be rinsed out 
with cold water, and, as a finishing touch, I advise that some 
lotion as Holmes' Fragrant Frostilla be applied to the lips, 
which have necessarily had much unpleasant stretching. 
When this technique is carried out, and the proper dental 
toilet explained, the patient is delighted and is usually will- 
ing to pay liberally for the services rendered. 

ABRASIVE MIXTURES USED IN CLEANING THE TEETH. 

Ordinary powdered pumice can be mixed with either tinc- 
ture iodine, alcohol, or peroxide of hydrogen. The iodine 
stains, the alcohol is the best antiseptic, while the peroxide 
is good to remove green stains. 

To a teaspoonful of pumice can be added about ten drops 
of aromatic sulphuric acid. This is splendid for tobacco 
stains. 



Abrasive Mixtures Used. 181 

The above should only be used where the teeth are in a 
bad condition. 

Flour of pumice is much finer, and should be substituted 
for the regular pumice, if possible. It can be mixed with 
any of the above drugs. 

If the teeth are in a fair condition, it is best to take a 
teaspoonful of any good dentifrice or tooth paste, and in- 
corporate with it a small quantity of flour of pumice. 

Any of the above can be used either with dental engine 
or hand cleaning with porte polisher. 



PART II. 
PRACTICAL ORAL PROPHYLAXIS. 



CHAPTER XI. 
ORAL PROPHYLAXIS. 

DEFINITION AND VIEWS OF SMITH, SPALDING, FLETCHER, 
FONES, THORPE, TAYLOR, RHEIN AND HARPER. 

It was some years ago at a meeting of the National Den- 
tal Association, in Washington, that I first heard anything 
definite on oral prophylaxis, and became interested in this 
subject. At this time it was my pleasure to listen to a 
paper read by Dr. D. D. Smith, of Philadelphia, and, a few 
days afterwards, to meet him personally in his office. This 
meeting changed my entire method of conducting practice, 
and led me into the channels of prophylaxis. While it is 
true that this subject of oral hygiene, prophylactic treat- 
ment and prophylaxis has been brought up in various meet- 
ings, there is no doubt that Dr. Smith was the first dentist 
to advocate a systematic treatment along this line. His first 
paper was read October 18th, 1898. According to his own 
statement, this paper excited no interest among the dentists 
themselves. Some years later, by inviting dentists to visit 
his office, and exhibiting a large number of patients to whom 
he had been giving this treatment, he convinced many of 
the leaders of the profession that this was really a new de- 
parture. It was interesting to note, that while many were 
interested, and went home to put the idea into practice, many 
criticised him severely. A dental college professor said that 
it was a great craze. Many said that it would polish away 
the enamel. Some said that a tooth held against a brush 
wheel was in time worn away, and that this would be the 
way with teeth under prophylactic treatment. 



1 86 Practical Oral Prophylaxis. 

Dr. Smith's plan of frequent treatment was based on the 
fact that tooth decay begins at a vulnerable point on the out- 
side and proceeds inward along the tubuli. It mattered 
not to him whether this disease was caused by lactic acid. 
He contended that the decay of teeth depended upon our 
care exercised over environmental conditions. To him the 
place of decay or the resting place of the bacterial plaques 
was to be forcibly removed. This being done, we have 
changed the tooth conditions from bad to good, and have 
removed the means by which decay and disease gain a foot- 
hold. 

In answer to the question, "What is Prophylaxis Treat- 
ment?" there can be no better answer than that written by 
the originator of this systematic treatment. 

"The treatment consists of enforced radical and system- 
atic change of environment of the teeth and perfect sanita- 
tion for all organs of the mouth. Experience having dem- 
onstrated that the most careful and painstaking are unable, 
with the agents commonly employed — as the tooth brush and 
dentifrice, tooth pick and dental floss, soaps, so-called germi- 
cidal washes or other agencies — to effect this end, the plan 
of forcible, frequently renewed sanitation by an experienced 
operator has been found indispensable. In detail, oral 
prophylaxis consists of most careful and complete removal of 
all concretions, calcic deposits, semisolids, bacterial plaques 
and inspissated secretions and excretions which gather on 
the surface of the teeth, between them, or at the gum 
margins; this operation should be followed by thorough pol- 
ishing of all tooth surfaces by hand methods (power polish- 
ers should never be used) , not alone the more exposed labial 
and buccal surfaces, but the lingual, palatal and proximal 
surfaces as well, using for this purpose orange wood points 
in suitable holders, charged with finely-ground pumice stone 
as a polishing material. Treated in this manner the teeth 
are placed in the most favorable condition to prevent and 



Definition and Views. 187 

repel septic accumulations and deposits, and not less to aid 
all efforts of the patient in the direction of cleanliness and 
sanitation." 

To my idea nothing short of the above meets the require- 
ments of prophylaxis. 

Dr. E. B. Spalding in a paper before the Michigan Den- 
tal Society said: 

"One, two or three treatments does not constitute pro- 
phylaxis. It is the constant watching, guarding and main- 
taining the mouth in a condition of health which constitutes 
oral prophylaxis." 

Another definition by Dr. M. H. Fletcher is as follows: 

"The name prophylaxis means preventive as you know, 
and is the work that should be done by the patient in cleans- 
ing the mouth. When a surgeon removes a foreign body 
from the eye or treats a wound in any manner he calls it by 
its proper name, viz., surgical treatment. When a dentist 
treats the disease of the mouth, he is not doing preventive 
work, but surgical work, just as any other surgeon does, and 
I think the dental profession should rise to the occasion, 
and prove to the medical world as well as to the laity that 
they are scientific men. This can only be done by using the 
proper terms to describe the locations and pathology. This 
will indicate that they know what they are doing." 

Dr. Fones calls prophylaxis, "the ideal service to the pa- 
tient." 

Dr. B. Lee Thorpe, in a paper on Prophylaxis, has well 
said: "No treatment, internal or local, has yet been discov- 
ered as a panacea for the removal of oral accumulations or 
for the cure of mouth diseases. The surgical removal, only, 
of deposits, brushing, polishing and massage, both by the 
dental surgeon at stated intervals and later by the patient 
daily is the only known method — the dental surgeon's real 
duty is not to see how many teeth he can fill, but how many 
he can save from decay — but his responsibility is not fully 



1 88 Practical Oral Prophylaxis. 

discharged until he has educated the patient to devote the 
necessary personal attention to maintaining a healthy con- 
dition after it has been re-established." 

In as much as the terms oral hygiene, prophylactic treat- 
ment, and prophylaxis have caused so much misunderstand- 
ing, it is not to be wondered at that this work has not found 
its way into the general routine of more dental offices. 
Granting that all we have said about oral hygiene, even if 
this is practiced to the fullest extent, it still remains that we 
must imbibe some of the spirit and intent of prophylaxis to 
carry out the treatment as it should be carried out. It is 
a lamentable fact that so few dentists in the United States 
do this work in a systematic way. In 191 1, I made a tour 
of most of the large cities of the United States, and, after 
hearing numerous papers, seeing exhibits at societies, and 
reading a mass of magazine articles on this subject, I real- 
ized that little had been done in the carrying out of system- 
atic work along this line, and few had imbibed the true 
spirit of preventive dentistry. On June 21, 191 1, I read a 
paper before the Florida State Dental Society upon the sub- 
ject, "Introduction of Oral Hygiene into a Dental Prac- 
tice." In this paper I gave some interesting correspondence 
contributing to the historical data of the subject of oral 
prophylaxis. This paper was published in the Dental Sum- 
mary in December, 191 1. I quote at length: 

"Several years ago the dental profession was confronted 
by the fact that one of its members, a competent dentist, a 
social favorite, a refined and cultured gentleman, had been 
blacklisted from membership in a swell social club for no 
other reason than he 'cleaned teeth.' Nor was this stigma 
on prophylaxis confined to the laity. Dentists seemed to 
think it beneath their dignity to clean teeth, and, if it must 
be done, it was relegated to the assistant. Others tell us 
that it takes a crank to work prophylaxis. Dr. Levi C. 
Taylor, of Hartford, wrote me on February 7, 1905 : 'I find 



Definition and Views. 189 

upon investigation that it (prophylactic) means a medicine 
or medical treatment, the word being very old in this con- 
nection.' Dr. M. L. Rhein took exception to this, and 
claimed it to be a word taken from the name of a tooth 
brush in 1882. Prophylaxis came into use in the sixties, 
and was defined by Donaldson, in 1874, very much as I de- 
fined it at your meeting, 'Surgical or manipulative treatment 
for the preservation of teeth. That both are a treatment 
no one will deny, but I do believe that each has a distinct 
meaning. Men and women both belong to the human fam- 
ily, but who would think of using the words interchangeably 
as meaning one and the same thing?' 

"Dr. M. L. Rhein wrote me a letter in June, 1905, in 
which he said, T don't believe it makes any difference 
whether you use the word as an adjective or a noun; what 
I said in Washington, was that I was the first person to in- 
troduce the word into dental nomenclature when I intro- 
duced the prophylactic brush in 1883, and, having first made 
use of the word in that sense, I thought its very use, by virtue 
of priority, entitled it to be used in this way.' 

"Dr. D. D. Smith wrote me on June 10, 1905, as follows: 
'Dr. Rhein is entitled to no credit for original work in this 
matter. He never heard of it or thought of it until I pub- 
lished my paper in 1898. Prophylactic refers to a remedy 
and should be used adjectively. The word prophylaxis is 
never used as an adjective but as a noun, the name of a pro- 
cess. Prophylaxis is not a preventive remedy, but a pre- 
ventive process. You will find these terms used interchange- 
ably in the dental nurse paper, and without any discrimina- 
tion.' 

"On June 18, 1905, Dr. Rhein again wrote me: 'Not one 
patient out of five hundred would understand your purport, 
although they may declare they do. I find it necessary to 
impress these truths upon them again and again to make 
them understand. I don't care a rap about what I call this 



190 Practical Oral Prophylaxis. 

treatment to my patients. I believe that what they can 
understand most plainly is the term to use, therefore, I 
never say prophylactic treatment or prophylaxis to them. 
Plain English is the best thing to use at all times with a lay- 
man. Therefore, I tell them that the cleaning and polish- 
ing of their teeth, and massaging of their gums, done fre- 
quently, is the best preventive treatment that we have in 
dentistry. It is all very well to use these words profes- 
sionally, but plain English is the best thing for our patients.' 
"Dr. Taylor, in discussing the name, says: 'Dr. Harper 
suggested that prophylactic was a noun derived from the 
Latin. So far he is right, but he does not go far enough. 
It is both a noun and an adjective, and has been applied to 
medicine for more than two hundred years. What does 
prophylaxis mean? It is of Greek origin, derived from a 
verb that means to stand guard before. There should be 
a distinct meaning to our words, and prophylaxis I would 
define as the surgical and manipulative treatment for the 
preservation of health, and many physicians, with Webster, 
define prophylactic as a noun and an adjective, meaning a 
medicine which preserves or defends against disease, and the 
same definition is given in the Standard Dictionary. Pro- 
phylaxis is a noun, meaning the art of guarding against, pre- 
venting disease, observance of the rules necessary to pre- 
serve health, preventive treatment. I believe the essayist 
intended to convey to us the meaning of what I would term 
Prophylaxis, the surgical or manipulative treatment for the 
preservation of health, and not the rinsing of the mouth from 
time to time with medicine in the expectation of establish- 
ing the health of the mouth. I criticised his use of the 
term, as I believe he means prophylaxis when he says pro- 
phylactic' 

"Dr. Harper says, 'Prophylaxis is derived from the 
Greek; I did not say it came from the Latin, I said dis- 
tinctly that ic, al, and ary are Latin suffixes, and that pro- 



Definition and Views. 191 

phylactic is the adjective form which means pertaining to, 
belonging to, or consisting of prophylaxis. Take the word 
atmospheric, which means pertaining to the atmosphere. 
You use the adjective form with the ic suffix, because you 
indicate something that pertains to atmosphere; also hy- 
gienic, as relating to hygiene. The word prophylactic is 
the adjective form which is used in referring to the noun 
prophylaxis. Prophylaxis is strictly the adjective form with 
the ic termination. At most, even if used as a noun, as in 
calling certain medicines or washes prophylactics, it is still, 
strictly speaking, an adjective qualifying the medicine or 
wash as to its uses and purposes, and referring to prophy- 
laxis.' 

"Leaving each individual to take his choice between these 
opposite opinions, and omitting any and all special methods 
of treatment, I shall at once introduce my subject by the 
statement which I believe will be generally accepted, that 
nearly all our dental operations are necessitated by unclean 
and infected mouths. Then is it not strange that we, as 
dentists, have failed to keep those mouths clean? Is it not 
strange that we have treated this abscess, filled this tooth, 
operated for disease of the gums, but still think it beneath 
us to clean the mouth and keep it thus so as to prevent these 
operations? I know there are many here who will say that 
they have practiced cleaning all their professional lives and 
that these things will happen anyway. But the fact remains 
that a thorough search has been made of all available dental 
literature, and no mention of systematic prophylactic treat- 
ment was made up to 1898. About this year two prominent 
dentists began to investigate those infected mouths, and to 
publish their views and results. Still few dentists took up 
the work. In public exhibitions the actual results were 
shown by submitting patients who had been under prophy- 
lactic treatment. Some were enthused and wrote of what 
they saw, but so little progress was made that the originators 



192 



Practical Oral Prophylaxis. 



nearly gave up hope, and, as one of them expressed it, 'went 
home tired, despondent, and with the feeling that he had 
done his best, and, that as the dental profession had re- 
pudiated his work, he would make no further effort.' 

"But they kept at it, and evolved a system of prophylaxis 
founded on correct etiologic principles. The results accom- 
plished have forced us to realize the wonderful develop- 
ment there is in store along this line, and we now see the 
dental journals teeming with some new phase in every issue. 

u In the past, our work has been the repair of diseased 
tissues; our studies in etiology yielded no practical results. 
Dentists of the future must study and practice etiology and 
prevention. Until our present views on oral prophylaxis 
were accepted and understood, etiology was the subject 
about which dental authors wrote volumes and spun theories 
that now seem ridiculous when we meet them in reading. 

"Detail would make this paper too long, and I shall con- 
fine myself to facts which have been well established. 

u ist, That the etiology of the larger per cent, of dental 
operations is traceable to local infection. 

"2d, That tooth decay is from without, and caused by 
constant contact with infectious material. 

"3d, That simple gingivitis, Riggs Disease, and enlarged 
glands, are rarely traceable to constitutional causes, as 
urema, or syphillis, but generally to an infected mouth. 

"If you accept these well-established truths, I can expect 
your interest in the remaining part of this discussion. The 
medical profession has just emerged from a transformation 
of its methods from all treatment to prevention and sanita- 
tion. For instance, instead of giving all their time to the 
treatment of malaria, medical men now turn to the cause, 
and, by sanitary measures, seek the death of mosquitoes. 
The up-to-date physician now watches the surroundings of 
his patients to prevent typhoid fever. He takes all precau- 
tions to prevent small-pox, scarlet fever, and diphtheria. 'To 



Definition and Views. 193 

cure is the voice of the past, to prevent is the Divine whisper 
of to-day.' 

"Dr. M. L. Rhein, of New York, and Dr. D. D. Smith, 
of Philadelphia, both believe alike that this is the most 
important part of a dentist's work, but they have differed 
decidedly as to how to put the work into execution. Dr. 
Rhein claims that all patients should be given the benefit of 
prophylaxis, but that if he did the work himself, he would 
have little time for anything else. The charge for the treat- 
ment would be a burden, for the patient to pay at the rate 
of $5.00 to $15.00 per hour for twelve treatments each 
year. He contends that the work is not so difficult, but 
that an assistant can soon learn to do it, and he has intro- 
duced to us the dental nurse, whose duty it is to perform 
this work for patients at a nominal charge. Dr. Smith, on 
the other hand, won't agree to any of Dr. Rhein's ideas, and 
contends that prophylaxis is the most difficult thing that the 
dentist can be called upon to perform. Inasmuch as it is 
the best thing that a dentist can do for his patients, and 
takes a great amount of skill, the patients should not go 
into the hands of an assistant, but that he must do the work 
himself and charge accordingly." 



CHAPTER XII. 
WHY IS PROPHYLAXIS NECESSARY? 

WHEN TO BEGIN PROPHYLAXIS. FREQUENCY OF TREAT- 
MENT. OBJECT OF PROPHYLAXIS. 

One question which will frequently be asked us is, "Why 
is prophylaxis necessary to-day when all these years up to 
the present time cleaning the teeth once a year was thought 
to be all that was necessary?" 

If you will go back a few generations, you will find con- 
ditions yery different from those of the present day. In 
the first place, eyen those who liyed in the cities liyed more 
of an outdoor life. The strenuous life of the modern busi- 
ness man was then unknown. The time for a meal was of 
much longer duration. In addition to this, the culinary art 
had not reached its present high state of deyelopment. 
Cooks in our time seem to haye for their chief object the 
preparation of foods for absorption through the intestines, 
and to dispense, as it were, with the duties of the stomach. 
They seem also to striye to prepare the food in as sticky 
a manner as possible. In this day and time, if food were 
put on the table which would require a proper amount of 
mastication we would think that something was surely 
wrong, our cook would think it an insult to our table and 
that such food should be run through the meat chopper. It 
is a rare opportunity when one of us makes a meal of such 
food that the teeth get to perform their real duties, that is. 
tearing, rending, and grinding. 

The interproximal spaces in our mouths which were in- 
tended to be closed up, are now wide open to receiye this 
sticky food. While we haye this sticky mass adhering to the 



Why is Prophylaxis Necessary? 195 

surfaces of the teeth it constitutes the best culture medium 
for the growth of the numerous bacteria which are always 
in the mouth. 

Disuse of any organ or of any part of the body results 
in the atrophy ot that part. Take, for example, the wide 
alveolar process with teeth embedded in thick peridental 
membrane that our forefathers had. They were capable 
of much greater chewing power than are the teeth of our 
present day with the thin peridental membrane surrounding 
them. And then we have that modern abnormality — the 
narrow arches and irregular teeth — making it necessary to 
carry out the most careful oral hygiene in order to keep 
the teeth free from sticky, doughy, tenacious foods. Also 
the teeth in our present day are submitted to various dele- 
terious influences in the way of food and drink condiments 
which are strong enough to etch a marble slab, and these 
are followed by an ice cold drink or steaming cup of coffee. 
Thus we see that cleaning the teeth was not so necessary 
with our forefathers as it is with us on account of the high 
degree of civilization, with its consequent dental degeneracv, 
to which we have attained. We might say that modern 
prophylaxis is to counteract this self-occasioned loss. In 
other words, we have to do by cleaning the teeth and prophy- 
laxis what used to be done by nature. The great number 
of tooth manufacturing houses throughout the land points 
to the necessity of finding some way by which this great loss 
of such important organs as the teeth can be checked. 

The medical profession has for years advanced along the 
lines of preventive or prophylactic treatment. The preven- 
tion of small-pox has been insured by vaccination. We have 
recognized the fact that the best work of our medical men 
is along the lines of sanitation. We have welcomed the 
preventive measures in our army for the checking of malaria 
and typhoid fever, and while all these are being constantly 
brought before our eyes, dentists not quick to accept the 



196 Practical Oral Prophylaxis. 

simple truths which are continually in their sight, are still 
making crowns, fillings, and bridges for these broken down 
teeth and are not recognizing that the crown of these teeth 
is not so important as the root, and the peridental membrane 
surrounding it. When we realize the nature and cause of 
all these diseased conditions, and when a system of prevent- 
ing it is at our hands, the neglect seems criminal. 

This thought is well expressed by Nodine, who says: 
"If the field in which dentistry works is as great as we 
are taught that it is; if clean mouths, and sound teeth mean 
as much as we read that they do; if the achievements and 
technical skill accomplish the results that we know they do ; 
if the world needs dentistry as much as we believe that it 
does — then we fail ignominiously in our obligation to so- 
ciety when we don't tell it the importance, the significance, 
the accomplishments and the needs of dentistry." 

Talks with parents in the dental office are not always given 
under favorable conditions and have not produced the proper 
results. Below is copy of a circular which a prominent 
dentist sends out several times a year with his bills to those 
having children under his care. Follow his example and 
spread these important facts. 

CARE OF CHILDREN'S TEETH. 

The proper care of children's teeth is of the utmost importance, and 
while it is a fact that the temporary teeth will be lost, it is nevertheless 
true that their neglect may bring about more serious results than the same 
neglect of the permanent teeth. 

As soon as the first tooth is well erupted the use of the mouth rag 
should be supplemented by that of a soft brush, and with this and clear 
water the troth should be carefully brushed every day. 

Immediately upon their full eruption, the surfaces which are in contact 
with each other should be polished daily by means of suitable floss silk. 

When the child has reached an age at which it will not swallow every- 
thing that is put into its mouth, precipitated chalk should be used upon 
the brush once a day. 

If the teeth were perfectly formed when erupted, this care should keep 
them in perfect condition, provided always that the proper diet has been 
insisted upon. 

Little children should not be allowed to eat candy or other sweets. If 
there is any agent which will ruin infant's teeth more quickly and more 
seriously than condensed milk, it is not known to the writer. 

Unless there is evidence of such necessity, the child need not be taken 
to the dentist until it is two years and a half old. At that age the teeth 
should be carefully examined by him, and again every three or four 
months. 



When to Begin Prophylaxis. 197 

However, if at any time dark stains accumulate upon the teeth near the 
margin of the gums they should he polished off. It is absolutely essential 
that all surfaces be kept clean and bright. 

The decay of these temporary teeth insures the child untold discomfort 
and pain, and usually interferes with the proper eruption of the second 
set. Owing to their nature it is most essential that all cavities should 
be filled in their incipiency. 

The extraction of any temporary teeth before the period for the erup- 
tion of their permanent successors usually interferes with the proper 
eruption of the second set. 

The first teeth of the permanent set to appear are the first molars, 
which should erupt at about six years of age and before any of the first 
set have been lost. These teeth should be kept under a watchful eye as 
they are very prone to decay. 

If at this age the arches have not grown, and all the front teeth so 
separated that one or two thicknesses of blotting paper can be put be- 
tween them, the second set are sure to be crowded and irregular — in such 
cases the arches should be expanded and the necessary space made to 
accommodate the larger teeth of the second set. 

While some children may contract unfortunate habits notwithstanding 
the most strenuous efforts being made to prevent their doing so. the 
permitting of a child to suck its thumb or fingers, or the giving it a 
"pacifier" is simply criminal, as most serious results must follow. 

The harmfulness of mouth breathing should he recognized and the nec- 
essary steps taken to cure it. 

During the eruption of the second teeth they should be given special 
care and should be examined at least twice a year and cleaned and pol- 
ished as often as necessary. Cavities should be filled in their incipiency. 

If the family dentist were charged with the duty of sending for the 
child at stated intervals, the chances of neglect upon the part of the 
parent would be minimized. 

Eternal vigilance is the price of good teeth in the child as well as the 
adult. C. EDMUND KELLS. JR. 

WHEN TO BEGIN PROPHYLAXIS. 

Our patients seem to think that decay in children's teeth 
is just a normal condition, for how often will a parent when 
told of the decay in a molar tooth say, "O that is only a tem- 
porary tooth," and seem no more to mind it than they would 
a bump on the face, when we know that the decay is serious 
because of its bearing on the future condition of the child's 
teeth. 

In the first part of the book we have learned the startling 
facts of what accumulation on the teeth leads to, and the 
logical reason why a systematic removal should be insti- 



30- s* 



Fig. 62. 



198 Practical Oral Prophylaxis. 

tuted. Dentists should be willing to give more of their 
time to this work. 

The necessity for and frequency of prophylaxis may be 
illustrated by what I term the Age Curve (Fig. 62). What 
is meant is, that children at the age of six years should be 
placed upon a regular and systematic prophylactic treat- 
ment for it is here that the care of the dentist is most 
needed. In my practice I have been astonished at the need- 
less loss of sixth year molars. It is for this reason that I 
say the most important time for prophylaxis is with children 
at the age of six years, for at this time we can have better 
control over the patients, and suggest to them habits which 
will lead them into proper hygienic rules. We can thus 
have the opportunity, at the proper time, of extracting the 
temporary teeth so that the permanent teeth will erupt at 
the proper places. This will save the parents much ortho- 
dontic expense and save these teeth from the very start. At 
this time the children learn the proper oral hygiene and 
dental toilet habits; later, as they are having to go to school 
or to work there will not be a good opportunity to get these 
ideas instilled into their minds. From the age of twenty- 
five to thirty there is a period of comparative immunity and 
I would not think that such frequent prophylaxis treatment 
should be necessary. After this time some of the work 
that was done in former years begins to fail and the rush 
of business and social life makes great demands on the vital- 
ity, so that more frequent treatments will probably be neces- 
sary. From thirty-five to old age, more stress should be 
laid on prophylaxis. 

In children the main thing we have to combat is dental 
caries. I have heard many dentists tell children that meat 
eating is the cause of these decays. If Prof. Miller's ex- 
periments are correct, he has proved that meat eating is not 
the cause of such decays. I believe that we should encour- 
age the children to eat meat, and, what is more important, 



When to Begin Prophylaxis. 199 

to leave off sticky foods. On the other hand, it is just as 
true that as the child grows older, these remains of meat 
left between the teeth become more dangerous on account 
of their tendency to cause pyorrhea. From twenty-five on, 
we are not looking so much to have to prevent caries, for as 
we have said, there seems to be a form of immunity to caries 
at this time, but the greatest trouble will come from some 
infection or disease of the peridental membrane, and we 
must look with all care towards saving this membrane in its 
integrity. Meat impactions and decomposition cause much 
distress and disease of the gum margin. The reason for 
this is that as the patient grows older (as in all other parts 
of the body) the alveolar process begins to undergo a senile 
change. In the first place the animal matter becomes less, 
the bone begins to solidify, and the blood vessels get smaller. 
The haversian canals can hardly be found. These changes 
give food debris a greater opportunity to irritate and infect 
the gums. 

It was once argued by some of the medical profession 
that the dentists did a great wrong when they tried to pre- 
serve a man's teeth after he had passed the age of fifty, for, 
said the essayist on the subject, "It is nature's plan to lessen 
the amount of food for the senile stomach." They claimed 
that if the dentists kept the teeth of the old people up to the 
standard that this would enable them to eat as when young, 
and that many of the ills to which old people were subject 
were caused solely by their ability to carry on active mas- 
tication. Dentists, and especially those engaged in prophy- 
laxis, now stand ready to refute this from every point. Of 
course, if the patient is one who has a very septic mouth, 
has bridge work which will not be kept clean, and toxins 
are generated around this the medical man has some justifi- 
cation for his belief that the patient named be better off 
without any teeth at all, but we have found that the old 
man on prophylaxis receives just as great benefits as the 



200 Practical Oral Prophylaxis. 

young person. This system will not only maintain oral 
cleanliness, but prevents, to some extent, the atrophy of 
the ligament attachment of the teeth. Old people who are 
on this treatment are very enthusiastic, and as free from 
general constitutional troubles as it is possible for them to be. 

FREQUENCY OF TREATMENT. 

In conclusion, children should be treated at least once a 
month, and persons from twenty-five to thirty about once in 
three months. From forty-five on the treatment should be 
given once a month. 

Frequently dentists on viewing the mouths of regular 
prophylaxis patients in my office have expressed the thought 
that it did not seem necessary for teeth so clean and in such 
good condition to have further treatment. This is the key 
note of the whole situation. It would be simply oral hygiene 
to clean the teeth, but here we have something deeper. The 
patients on prophylaxis come to us not for cleaning, but for 
the results in the true meaning of prophylaxis — the guard- 
ing of the oral cavities from the entrance of infection. 

In prophylaxis we presuppose that all adhesions have 
been removed and all tendency towards any pathological 
condition has been eradicated and that the treatment will 
be directed to those places which the patients themselves 
can not reach. 

OBJECT OF PROPHYLAXIS. 

The claim of Smith, that the peridental membrane is of 
more importance than the crown of the tooth, has been 
borne out by investigation of the origin of pyorrhea, and 
the quicker this is recognized, and the quicker we diagnose 
any inflammation at the gingival margin of the peridental 
membrane, the more certain we will be of freeing our pa- 
tient from any possible danger. There is some doubt 
whether there is ever a reattachment of the pericemental 



Object of Prophylaxis. 201 

fibres after they have once been detached by disease. This 
emphasized the necessity of prophylaxis as a preventive of 
pyorrhea. 

We have learned that the caries of the teeth are depend- 
ent for the most part upon two formations, the carbo-hy- 
drates and micro-organisms. As neither of these factors 
can be eliminated, all that we can do is to learn as much as 
possible how to hold either or both of these elements in 
check. Unfortunately, the very articles of which we eat 
most freely, that is, pastry, candy, etc., give the largest per- 
centage of carbohydrate and acid units. 

As it is difficult at the present time to control the matter 
of diet the object of prophylaxis should be to eliminate as 
far as possible the effects, and certainly the first question to 
be taken up is that of loglbility. Thus we find that those 
substances which are either alkaline or neutral in effect 
are chocolate, biscuit, milk, dates, etc., while substances such 
as potatoes, lemons, pine apples, nuts and meats, being orig- 
inally acid in reaction, are beneficial. 

The conclusions which are reached by Pickerill after con- 
siderable experimentation along this line, are: 

"That in order to prevent the retention of fermentable 
carbohydrates on and between the teeth, and so eliminate 
or very considerably reduce the carbohydrate factor in the 
proportion of caries, starches and sugars should on no ac- 
count ever be eaten alone, but should in all cases either be 
combined with a substance having a distinctly acid taste, or 
they should be followed by such substances as have been 
shown to have an 'alkaline potential,' and the best of these 
are, undoubtedly, the natural organic acids found in fruit 
and vegetable." 

Those races where comparative immunity from decay is 
found, undoubtedly produce the result by the constant use 
of salivary stimulants producing in the salivary glands a 



202 Practical Oral Prophylaxis. 

constant activity which prevents stagnation in the oral cavi- 
ties, and thus preventing predisposition to decay. 

Several references have been made heretofore to the soft- 
ness and stickiness of our foods which, lodging between the 
teeth, give a start towards caries. The child's taste is a 
guide which, instead of giving heed to, we have always 
sought to ignore. The child naturally calls for the articles 
of diet having an acid reaction, fruits, salads, candies, etc. 
The harm does not come to the child's teeth from these sub- 
stances, but from the form in which they are eaten — sticky, 
doughy cake for example, sticks between the teeth and stays 
for future decomposition. I have no doubt that candy in 
the pure state is not only non-detrimental, but of great food 
value, and a preventive of decay. We may well consider 
the food, and lunches furnished to the children as a probable 
cause for these defects, in that most of the meals are made 
up of salivary depressants. Added to this fact, we must 
remember that the debris stays around the teeth, and be- 
tween them until the next meal. The child's prophylaxis 
should begin by recommending to the child or his parents 
the addition of more fruit to his diet, and that this fruit be 
eaten, not before the meal, but after it in order that the 
salivary glands may become excited, and remain so until 
the debris is rendered soluble or washed away by the flow 
of saliva. We, as dentists, formerly thought that salads 
and condiments were very detrimental to our patient's teeth. 
However, used in the right way, there can be no detrimental 
action. 

Tea is one of the salivary depressants, and should not be 
given to children at all; if our grown-up patients use it, we 
should insist that they do not end a meal with this drink, 
but use it in the first part of the meal, for, used in the latter 
part of the meal or with the dessert, it stops the flow of saliva 
for some time, allowing the micro-organisms of the mouth 
to multiply very rapidly. Some one has said that were 



Object of Prophylaxis. 203 

lemonade drunk as a universal beverage it would be impos- 
sible to have typhoid fever. This alone is a recommenda- 
tion for this most excellent beverage, but, when we couple 
to this, the fact that fruit acid is one of the greatest salivary 
stimulants, we should not fail to take advantage of its bene- 
ficial qualities. 

All this leads us to the fact that the aid we secure from 
nature in the prevention of caries must be through increas- 
ing the activity of the nerves leading to, and having control 
oi. the salivary glands. These being brought to their high- 
est development, we have a prophylactic fluid far superior 
to anything that can be made artihcally. We can accom- 
plish by mouth washes and dentrifices some things ( dealt 
with in a later chapter) but let us start off our prophvlaxis 
with the knowledge of the fact that nature has this great 
preparation ready to manufacture at our suggestion. 



CHAPTER XIII. 
THE PROPHYLAXIS CLASS. 

PRELIMINARY WORK BEFORE ENTERING PATIENT ON PRO- 
PHYLAXIS. PROPHYLACTIC TECHNIC. VIEWS OF 

KELLEY, GOBLE AND JOHNSON. 

When we have finished our dental work, and have taught 
our patient the importance of oral hygiene, the question 
which will be asked the doctor is, "Now, doctor, what can 
I do to keep my mouth in this condition, and how often 
must I come back for examination?" If the facts and argu- 
ments which have been brought forward in this book have 
been of interest to you, it is hoped that you will start what 
I call the "Prophylaxis Class." This is somewhat original 
with me. I tell my patients, that if they are serious in their 
desires, I will take them at a nominal fee for one year if 
they will agree to come as often as I think necessary to keep 
their mouths in perfect condition. There is no use to ad- 
vise patients to go on prophylaxis while you have reason 
to believe that they will not carry out your instructions, 
for it is a waste of time and embarrassing at the end of 
the year to find that the patient's mouth is in no better con- 
dition in spite of all your work. Many times, however, I 
have seen a gawky boy who was a perfect stranger to a tooth 
brush, after six months of this treatment, acquire oral hy- 
giene habits which he would follow all his life. Young 
girls would probably be the best to enter upon this treat- 
ment in beginning this work. I do not want any one to 
enter the class on the first blush of enthusiasm. I generally 
give them a reprint on the subject to take home and read. 
My policy of educating patients is to select some good article 



Preliminary to Entering On Prophylaxis. 205 

appearing in a dental journal and secure from the author 
the necessary reprints. I have always found the author 
glad to supply them. Then, if they are willing to fulfil the 
demands made on them, I gladly place them upon the list. 
One of the worst difficulties in getting the patient ready for 
prophylaxis is banded crowns, cement and gutta percha fill- 
ings. These necessitate considerable dental work. We 
should have some every-day illustration to use in explaining 
to the patient the necessity for having this work done, in 
order to show them that it gives lodgment for debris which 
would overcome all our efforts at prophylaxis. 

PRELIMINARY WORK BEFORE ENTERING PATIENT ON 
PROPHYLAXIS. 

Before the treatment is begun all dental work must be 
brought up to the standard. All roots of teeth, which can 
not be saved, must be extracted. All meat holes and fillings 
with bad contours must be corrected. All tarter must be 
removed, and the teeth put in a hygienic condition as de- 
scribed under "Cleaning Teeth." All this, of course, must 
be paid for at regular fees, for, as I have said before, pro- 
phylaxis presupposes a perfectly clean mouth. 

Fones gives the illustration of two pieces of glass each 
five inches square. One of these is ground, and the other 
polished plate glass. Both are smeared over with the debris 
which we would find in the average mouth. With one sweep 
of the tooth brush it is easy to clean the polished surface, 
while it takes several motions to clear the ground glass sur- 
face. Another illustration is the cement slab at our chairs. 
When this has become scratched or rough, we find difficulty 
in removing the cement left over from our operation. On 
the other hand, when the slab is new and free from these 
defects, it may be cleaned by simply placing it in water and 
wiping off the cement. Now the same thing holds true in 
the mouth. If the patient is on prophylaxis and the teeth 



2o6 Practical Oral Prophylaxis. 

kept in the proper state of polish by the monthly treatments, 
he can with one sweep of the brush remove any deposit 
which may have settled on the teeth, but if this food debris 
is held by accumulations of tartar, as found in the average 
mouth, it can only be removed by a dentist. 

PROPHYLACTIC TECHNIQUE. 

A few years ago at one of the state societies where I was 
giving a clinic, a countrified-looking dentist pushed himself 
to my side and said, "What the devil is a prophylaxis treat- 
ment anyhow? One of your patients moved to my town 
and insisted that I give her a prophylactic treatment. I 
wrote to you to find out what it was, but the answer must 
not have been correct as I gave her a treatment and she 
never returned." An explanation of the conditions which 
necessitate prophylaxis makes a much greater impression 
than the statement of the simple technique necessary to bring 
about the results. In the art gallery, we stand enthralled 
before some master painting, we live with the person or in 
the scene which it depicts, and enter into the vision which 
caused the picture to be painted. Had we been in the studio 
where this work was done, we would probably not have 
shown any interest in the small brushes and pallettes of paint 
with which the artist made the picture. Thus I have found 
that I could interest dental students and keep up their en- 
thusiasm until I began the description of the technique. They 
expected something big, and when I told them of its sim- 
plicity, the enthusiasm had a tendency to drop. The tech- 
nique of Prophylaxis is nothing more than the technique of 
cleaning the teeth, only carried out to a much greater nicety, 
and, in addition, the regularity with which it is carried out. 
One prophylactic treatment will not amount to much, but 
the effect of a half dozen of these treatments, each one over- 
coming some defect, makes a vast difference between these 
two operations. 



Prophylactic Technique. 207 

Dr. Henry A. Kelley says: 

"In beginning our spraying and polishing, the first condi- 
tion that confronts us is a viscid coating of saliva and gel- 
atinous plaques that covers the teeth and gums. First take 
a tube of rather hot water, of about 150 F., to which has 
been added one dram of aromatic spirits of ammonia. The 
alkalinity of this spray, applied under a pressure of from 35 
to 50 pounds, will overcome this viscidity. After thorough 
spraying with this first spray, alternate with a second spray, 
composed of three-quarters of a tube of warm water and 
one-quarter of a tube of some of the forms of hydrogen 
dioxid. To this tube add a few drops — three or four — 
of essence of anise to disguise the very unpleasant hydrogen 
dioxid taste. This second spray is used on account of its 
cleaning effect. As the dioxid comes in contact with the 
decaying particles of animal matter we have the well-known 
boiling effect, which tends to lift out and off all foreign mat- 
ter accumulated around the teeth. Then with a hand porte- 
polisher (I use Harrell's) charged with flour of pumice 
begin the polishing. The pumice must be moistened with 
water to make a paste not too thin, to which two or three 
drops of essence of peppermint are added. The pepper- 
mint serves not alone to take away the sandy taste, but also 
to exert a cooling effect on the gums, and leaves a refresh- 
ing and clean taste in the patient's mouth after the operation 
is finished. I usually go over all the teeth in a rather hur- 
ried way in order to first get rid of any matter adhering to 
the surfaces, and then after another spraying, alternating 
with both sprays, I pass to the last tooth on the upper left 
side and go over all the buccal and labial sides of all the 
upper teeth, going into the approximal spaces as well as pos- 
sible with the porte-polisher. Use flattened orange-wood 
points for the flat surfaces, applying considerable force with 
a circular movement directed from the neck to the cutting 
edge and just under the gum margin. This gum margin 



2o8 Practical Oral Prophylaxis. 

is a very important region, and it is probable that if this is 
kept well polished your patient will never have pyorrhea, 
or if he has had it, it will never return. Having gone 
around to the last tooth on the upper right side, spray again 
with the second spray, and return to the last tooth on the 
upper left side, going over the lingual surfaces and then 
spraying with the second solution. Then polish your grind- 
ing surfaces. The same process is followed with the lower 
teeth. Go over all exposed surfaces with your porte-pol- 
isher charged with tin oxid made into a paste, which will 
impart a beautiful polish to these surfaces. Then apply a 
thorough spraying with a third solution, which consists of 
one-half a tube of hot water to which has been added one- 
half a tube of some pleasing general mouth-wash (I use 
Alkalyptol, which I find very satisfactory; not all antiseptic 
mouth-washes leave the same refreshing taste in the mouth), 
and pass waxed floss between all the teeth and clean out the 
interproximal spaces, spraying with the second solution as 
necessary. After that finish with the third spray, finally 
allowing a rinsing-out with a glass of cool water. If your 
work has been thorough, your patient has the first sensation 
of what a clean mouth means. Patients often tell me that 
they hate to go home and eat and soil the mouth again. 

"It is well to alternate from month to month, taking the 
upper teeth first in one month and the lower teeth first the 
next month. I find that for some reason which I can not 
explain, the upper teeth respond to treatment, especially in 
pyorrhea cases, much more readily than the lower and I have 
these two thoughts to offer in this connection. I find that 
when I begin with the upper teeth I often spend forty min- 
utes going over them, which leaves me but twenty minutes 
of the hour appointed for the lower; hence the practice of 
alternating from month to month. The pumice also be- 
comes much thinner from the admixture of saliva in polish- 
ing the lower teeth. I often use the saliva ejector or nap- 



Prophylactic Technique. 209 

kins to offset this latter condition, but I can not as yet say 
with what result. When you first begin to polish with the 
pumice, your wood point will slip over the tooth, and there 
will be a slimy, greasy sensation. But as you polish and 
polish, you get down to the clean tooth-surface, and then 
you experience that squeaky sound that indicates a clean 
tooth-surface. The slimy substance that you are removing 
is composed of the gelatin-forming micro-organisms, w r hich 
I shall explain later in a quotation from Johnson. Hence, 
if you make every filling smooth, allow no shoulder, or lodg- 
ing-place for the decay-producing germs to remain, and then 
destroy the gelatinous film under which the micro-organ- 
isms that cause decay are enabled to effect their destructive 
process, you render it extremely hard for decay to begin or 
make progress." — From Dental Cosmos. 

Dr. Kelley suggests the use of a nasal spray tip, made by 
Debilbiss Co., which he uses to spray out the inter-proximal 
space from the buccal side. Place the index finger just over 
it (that is above it, on the upper, towards the root end) draw 
it back just a little and spray. The spray thus goes beyond 
the tooth and out on the palatal side. Following this sug- 
gestion Dr. Kelley says: "The patients realize how you have 
cleaned the teeth." 

The first step is the use of a small scaler of the Younger 
type (with its sharp edge removed) which is gently inserted 
under the free margin of the gum and carried around the 
entire gingival portion, being careful to exert no force on 
the instrument which would in any way tear the attachment 
at the peridental margin. I consider this the most impor- 
tant part of prophylaxis for it is this membrane above every- 
thing else which must be protected. It is here that the be- 
ginnings of deposits may be detached in their incipiency. No 
porte polisher or pumice will do this; only skilled touch and 
the proper instrument can do it. 



210 Practical Oral Prophylaxis. 

The mouth in which there has once been a pyorrheal con- 
dition will often call for a fine point of judgment, for it is 
often necessary to enter forcibly into these former pyorrhea 
pockets and clean them out thoroughly. This, if rightly 
done, can do no possible harm, and certainly is the means of 
preventing future eruptions from some infection forcing its 
way into these places. If this is done every three or four 
months it will in time do more to eliminate this scar than 
any other treatment. It seems that with each treatment 
the pockets get shallower. 

Use dental floss immediately after instrumentation for 
the reason that at this time the mouth has no accumulation 
of powdered pumice which would make it most difficult to 
pass silk between the teeth. Do not put the abrasive on the 
silk and then attempt to pass it between the teeth. Pass 
the silk in first, and then place on a small amount of abra- 
sive. The same procedure is repeated at each interdental 
space. The largest and broadest floss silk that can be passed 
between the teeth should be used; this is the danger line at 
which we make our greatest fight against caries and the sim- 
ple running of the floss silk between the teeth will not ac- 
complish the desired results. According to late investiga- 
tions by Pickerill, it might be better to substitute for the 
spray containing aromatic spirits of ammonia, to overcome 
the viscidity of the saliva, some vegetable acid spray which 
will not only give an increased flow of saliva, but will fur- 
nish the protective qualities which it possesses, and will re- 
main for some time after the prophylactic treatment; this 
flow of saliva is undoubtedly inhibited by an alkaline spray. 

Dr. Gillette Hayden called my attention to the use of 
powdered sodium citrate for the removal of mucus collec- 
tions. Dr. Cook, of Chicago, endorsed it, claiming that it 
attacks only organic substances, without detriment to the 
teeth or the soft tissues. It can be used at the chair in con- 
nection with the abrasive used in the treatment, but must 



Prophylactic Technique. 211 

not come in contact with any moisture previous to the time 
of using it. Use it with water instead of any other fluid 
as it combines readily with other substances. 

Opposed to this system of prophylaxis, is that of Dr. 
L. S. Goble, who writes of his technique in a recent number 
of the "Dental Dispensary Record." He prefaces his re- 
marks by saying that for twenty years he has been doing 
prophylaxis work in spite of uric-acid and rheumatic dia- 
theses, and found that the only way to properly carry out 
prophylaxis was to remove the tartar, and keep the mouth 
clean. He further says that he is not in sympathy with the 
so-called "Prophylaxis Movement." 

"Like the cry, 'On to Richmond,' we yell, 'Remove the 
Plaques,' and so the whole mouth is scrubbed and the gums 
are punched and stain is used, all on the basis that a micro- 
organism is the cause of caries, although it has not been iso- 
lated and the theory has not been proved. Do the plaques 
stay removed? No, they return in full force in six hours 
and in some people's mouths in two hours, showing that 
the micro-organisms are always there and rightfully there. 
You may ask, 'What do you say then? Let the plaques 
alone?' No, I say remove them in so far that you do not 
injure the gum tissue and only that far. And this putting 
stain on the teeth and then tearing the mouth to pieces get- 
ting it off, just to show the patient where the plaques are, I 
consider a mistake or worse. And to have all your patients 
come once a month for prophylaxis is rank nonsense, and I 
have seen many evil effects from it. I have, and you have 
patients whose mouths after three months have no more 
plaques than other patients have after six hours. The 
former under the monthly rule, you would rob, the latter you 
would be neglecting. I have patients that come year after 
year and who need no oral prophylaxis and yet I have no 
doubt that I could show plaques. I do not believe that 
plaques cause decay, but as a media for the acid of fermenta- 



212 Practical Oral Prophylaxis. 

tion going on in the mouth they may cause one per cent., I 
doubt if it is more." 

The above quotation of Dr. Goble is rather extreme and 
yet such expressions are useful to curb our ultra-enthusiasm 
for this new departure. Along the same line of caution we 
read from the pen of Dr. C. N. Johnson, in a recent paper 
(Dental Society of the State of New York, 1915 ) the bad 
things we must omit in our prophylaxis work. 

"To prevent disease is more laudable always than to cure 
it, and our chief efforts should be centered in this direction. 
But in his wildest day-dreams the man who first called atten- 
tion to this practice, Dr. D. D. Smith, of Philadelphia, never 
imagined the extent to which it was to be carried by some 
practitioners. To conscientiously remove deposits from the 
teeth and polish the surfaces smooth and bright where they 
had become stained and roughened, is a legitimate and alto- 
gether worthy method of practice, to stimulate patients to 
better care of the teeth and to have constant surveillance 
over conditions in the mouth by frequent stated inspections 
must be considered a policy of reason and conservation. But 
to ruthlessly go into a mouth with stones and disks and 
strips, and to grind and cut and slash as is being done by 
some operators is wholly unwise and in certain instances 
borders almost on malpractice. To saw this strip back 
and forth in the interproximal space, lacerating the gum to 
shreds, and cutting into the tooth tissue in the gingival re- 
gion, in many instances, does more harm than good. There 
is no need for creating this discomfort if the operator will 
go about his prophylactic work with reason and judgment, 
removing the deposits most carefully with delicate instru- 
ments and polishing and smoothing the tooth surface without 
cutting and slashing into it as if it were so much inert matter. 
To transform a mouth from a state of disease to one of 
health by prophylactic treatment and do it rationally is a 
process extending over some time instead of a radical and 



Prophylactic Technique. 213 

immediate operation of the 'presto change' character. And 
this can be done without subjecting the patient to intolerable 
pain or subsequent discomfort. 

"Another consideration connected with the practice of 
prophylaxis relates to the folly of instituting treatment of 
this sort in a perfectly healthy mouth. This is frequently 
done on the plea that it will prevent disease of the gum and 
decay of the teeth, and the promise is confidently made by 
the dentist and naively accepted by the patient that if pro- 
phylactic measures are followed once a month there will 
never be any caries or pyorrhea in that mouth. The burden 
of preservation is thereby placed upon the dentist instead of 
being placed where it properly belongs, upon the patient. 
It is the daily care the patient gives the teeth rather than the 
monthly care of the dentist which counts most for the main- 
tenance of health, and this should always be emphasized in 
any discussion of the matter with the patient. * * * * 

"Then again to promise a patient that there will be no 
decay of the teeth if prophylactic measures are instituted 
each month is a hazardous thing to do. In some mouths 
where the influences of susceptibility are especially active, 
cavities will occur at times despite our best efforts, and when 
this happens it must call for some very ingenious explaining 
on the part of the dentist. Fortunately for themselves 
some of our colleagues are really very ingenious at this kind 
of explaining; but it would assuredly be better for their sub- 
sequent equanimity if they were frank enough at the outset 
to say to their patients that while prophylaxis is a most ex- 
cellent procedure under its proper indications and will aid 
greatly in minimizing the tendency to decay, that there is 
yet no panacea or absolute preventive for dental caries 
known to man. This would be safer, and I venture the as- 
sertion that it would not lessen the ultimate respect the pa- 
tient has for the dentist or for prophylaxis." 



CHAPTER XIV. 

INSTRUMENTS AND POLISHING MATERIALS 
USEFUL IN PROPHYLAXIS. 

Authorities do not agree as to what constitutes the proper 
instrumentation for prophylaxis. Some advise against the 
use of anything like a scaler, while others advise the regular 
use of a delicate scaler under the free gum margin, and the 
reopening and cleaning out of old pyorrhea pockets at fre- 
quent intervals. 

The condition before treatment, and the present state, 
together with a full understanding of the normal and patho- 
logical picture presented by each case, must govern the 
operator on this question. 

Instrumentation used with a proper knowledge of the 
demands of true prophylactic treatment can only be pro- 
ductive of good. Whatever points selected and used should 
have the sharp edges removed. 

The various shapes of spoon excavators can be made into 
most excellent instruments by removing the edge with a 
stone. Many of the instruments hereafter described for 
pyorrhea work are also useful in prophylaxis. Numbers 3, 
4 and 15 of the Good set have been of greatest service to 
the writer. 

INSTRUMENTS FOR HAND POLISHING IN 
PROPHYLAXIS. 

There are a great many porte polishers on the market 
which are herewith illustrated (Fig. 63.) Dr. Harrell in- 
vented the best instrument ever produced for the purpose of 
prophylactic treatment. The sale of this prophylactic pol- 



Instruments for Hand Polishing. 215 

isher is now controlled by the Oxylene Company of San 
Antonio, Texas. 

In the porte polisher various kinds of points can be used. 
Generally, however, they are made of orange-wood, and 
shaped out into a point or into a wedge. In addition to 
the porte polisher, it is well to have about a dozen large 
size orange-wood sticks sharpened into various shapes for 
immediate use. The wide points should be used on the 
broad sides, and the small ones between the teeth and in 
the fissures. 

A new point must be placed in the porte polisher for every 
patient for as soon as patients begin to learn something 
about prophylaxis, the treatment and technique, they are 
very particular and watch very carefully to see that every- 
thing is as aseptic as it should be. If the sticks of orange- 
wood or bass-wood be used, the wood should be washed 
carefully, a new point cut, and the sticks kept in a glass jar 
filled with antiseptic solution. Before I began doing this, 
I frequently had patients ask me if I used the same stick 
on all of the patients. 

Dr. Kelley suggests the use of strips of shoe peg wood, 
which can be cut to the exact width required. He claims 
that these have the advantage of orange-wood sticks in 
that they give an expansive flat surface for polishing the 
flat surfaces of the teeth, and that they are much superior 
to the regular orange-wood sticks. They can be procured 
very cheaply at any shoe factory or wholesale shoe shop. 
Dr. F. H. Skinner furnishes with his instruments, a box of 
prepared orange-wood points which are excellent. The 
S. S. White Dental Manufacturing Co., and the J. W. Ivory 
Company, make a specially shaped point, for use in porte 
polishers, which is quite an advantage in some places. The 
greatest aid as a substitute for the orange-wood stick is the 
contribution of Dr. J. W. Jungman, which consists of round 
bass-wood sticks about six inches long, which are placed in 



2l6 



Practical Oral Prophylaxis. 




Fig. 63. The Best Forms of Hand Polishers for Prophylaxis Work. 



Instruments for Hand Polishing. 217 

a 1 to 1000 solution of bichloride with green soap. They 
should remain in this until thoroughly saturated. (Fig. 64.) 



Fig. 64. 

Dr. Jungman furnishes me the following formulae which 
he prescribes and dispenses to his patients for use on their 
brushes. These also make excellent stock preparations for 
use at the chair to charge the bass-wood polishing sticks: 

No. 1 No. 2 

Prescribe in cases of pyorrhoea Where it will not permit a gritty 

where the enamel will permit the powder. 

use of a gritty powder. Pulv. Castile Soap Parts % 

Pulv. Castile Soap Parts % Sacch. Alba. Pulv " I 

Zinc. Sulpho Carb " I Oxide Tin, (Merck's).. " 4 

Pulv. Pumice (Fine)... " 6 Zinc. Sulpho Carb " 1 

Oxide Tin, (Merck's).. " 3 Creata Precip " 12 

Creata Precip " 12 Flavor, Q. S. 

Flavor, Q. S. 

No. 3 No. 4 

In well-kept mouths where no In acid mouths. 

medicament is required. Pulv. Castile Soap Parts % 

Pulv. Castile Soap Parts % Sacch. Alba. Pulv " 1 

Sacch. Alba. Pulv " 1 Oxide Tin, (Merck's).. " 3 

Oxide Tin, (Merck's) . . " 3 Sodium Borate (Squibb's) " 2 

Creata Precip " 12 Creata Precip " 12 

Flavor, Q. S. Flavor, Q. S. 

I secure large mouthed bottles, such as those used for bar- 
bers' pomade, which hold about one-half pint. Into these 
I put the various stock mixtures which I use in prophylactic 
work. 

From the ten-cent store I secure about one dozen old- 
fashioned open salt cellars. Just as soon as the instrumenta- 



218 Practical Oral Prophylaxis. 

tion is finished, the assistant places on the table two of these 
little glass receptacles. These are filled from the stock 
bottles. One contains whatever cleanser or abrasive the 
case calls for; the other, the finishing or polishing mixture. 
The cleaning mixture is best used moist, while the polishing 
powder is used dry. 

In beginning this work, we must be cautious not to use 
the common pumice stone, as it will cause cupping in at 
the cervical margin of the teeth. From the use of this heavy 
abrasive, I have noticed cups in the teeth of a number of 
patients. After the patients have been on the treatment 
for several months it is not necessary to have this abrasive 
used every time. The finer mixtures of oxide of tin, pre- 
pared chalk, or the various preparations on sale for this 
special purpose may be used. The views of Dr. Carmichael 
on the subject of the abrasive for use in prophylaxis are in- 
teresting: 

"The polish or gloss of enamel was put there by nature to 
protect the teeth from diseases. If this highly glossed sur- 
face of the tooth enamel was retained, foreign matter could 
not readily adhere and if the surfaces were always polished 
to the gum margin, the teeth would not decay, nor would 
there be dental pyorrhea. 

"All the substances in general use for cleaning teeth are 
harsh and gritty; though they be very fine grit, they accom- 
plish the purpose only by a scouring process, thus gradually 
destroying the natural gloss of the enamel. Although these 
scratches are not visible to the naked eye, they are sufficient 
to destroy the brilliancy, and leave the surface all the more 
susceptible to receive foreign adhesions; in other words, the 
more we scour the teeth, the more we must scour, to keep 
them clean; to say nothing of destroying the life luster: as 
proof of this, it is only necessary to dry the teeth to disclose 
the fact that the enamel gloss has been dulled. 



Instruments tor Hand Polishing. 219 

"It may be necessary, nevertheless, for the dentist to 
apply a very finely powdered abrasive to remove stains in 
cleaning teeth, and this should not be used over the entire 
surface of the teeth, but confined to the stained area, using 
a preparation of a character that will not scratch. 

"Experience has proved that a friction dry rub is not only 
more effective in removing the adhesions, but the life luster 
becomes more intensified. 

"The enamel must be kept so brilliant that the teeth will 
ward off disease. To accomplish this, we must adopt those 
measures that will restore the teeth to a state of nature, 
which is in line with the highest attainment in dentistry." 

In the use of any polishing instrument bear in mind the 
curvature of the teeth, and do not rub in one place, up and 
down, but follow the curvature of the teeth in a circular 
motion, and at a slow rate of speed. In this manner, we 
are enabled to feel any accumulation which we wish to re- 
move. If the point slips over the tooth as though it were 
greased, we know that it is enveloped in a secretion which 
must be removed. We must educate our fingers up to this 
delicate sense of feeling. We soon learn that a regular 
patient's teeth feel entirely different from one who has not 
had this care. There is a peculiar squeek of the patient's 
teeth, and the minute we hear this, we have caught on to the 
proper manner of handling our porte polisher. Just at the 
free margin of the gums it must be polished very carefully. 
Many operators, through too rapid movement of the porte 
polisher or through fear of injuring the gums, lose much of 
the importance of this work. I have not found the contact 
of the porte polisher against the gums to be injurious, if 
rightly used. 



CHAPTER XV. 

PROPHYLACTIC TREATMENT OF FISSURES 
AND GROOVES, SOFT SPOTS AND SENSI- 
TIVE AREA TREATMENT. 

FISSURES AND GROOVES. 

As previously mentioned the fissures, grooves, and pits 
in the teeth will cause us the greatest amount of trouble. 
The first time that this condition occurs in the mouth is fol- 
lowing the eruption of the first lower molar. It has been 
my practice for years to attend to these teeth as soon as 
they appear through the gums, whether the patient is on 
prophylaxis or not, but certainly if on prophylaxis. The 
tooth should first have the sulci cleaned out with a fine 
pointed instrument. The surface of the tooth is then 
cleaned off with some mild abrasive. The tooth is kept as 
dry as possible, and then sterilized with absolute alcohol. 
When this is done, the whole erupted surface of the tooth 
is covered with some quick setting cement. Many prefer 
one of the copper cements, but I have never seen any ad- 
vantage in using it. The erupting permanent tooth being 
behind the temporary molars, at a lower level, furnishes a 
depression which forms an ideal catch basin for decaying 
foods. Again, if the children brush their teeth, which they 
seldom do at this age, it is doubtful whether they ever clean 
this surface. As the tooth grows up into place, the chewing 
of food soon wears all the cement away except that portion 
in the grooves. As soon as the tooth is brought into use 
for mastication, if this cement has not been worn away, it 
can be removed, and in many cases we will find that no 
further attention is necessary. However, if deep sulci have 



Soft Spots and Sensitive Areas. 221 

developed, we can, with a real small burr, cut the fissure just 
sufficient for a small gold filling, or, perhaps, the little 
groove can be filled with cement (Fig. 65). It will be sur- 
prising to note how this will last in this small line cavity. 




Fig. 65. Fissure ix Lower Bicuspid (Solbrig). 

Such a tooth, unless properly treated, is almost sure to develop a 
serious decay in the fissure. 



Sometimes the simple opening and bevelling of the walls 
that lead to the sulci so that the tooth brush can reach down 
into it, is all that is necessary. The grooves in the buccal 
surfaces of the teeth should be ground out w T ith the smallest 
stone possible and then the surface thoroughly polished. 
However, if the groove is of such depth that the grinding 
will go through the enamel, or, as is often the case, a small 
pit shows somewhere along this groove, it can be filled with 
a cement filling, as this is probably the best to put in this 
position. 

SOFT SPOTS AND SENSITIVE AREAS. 

Soft spots at the juncture of the teeth and the enamel 
margin where previous recession of the gums has taken 
place, have proved one of the most disappointing operations 
in prophylaxis, and yet I feel that the percentage of success- 
ful work along this line is sufficient to warrant me in giving 
the technique; it is certainly worth while to try this method, 
even if the tooth should require a filling some years later. 



222 Practical Oral Prophylaxis. 

Small white spots in children's teeth can be polished away. 
The method of doing this is to take the smallest size mount- 
ed stone, grind down to hard surface, and then apply cuttle 
fish discs, and finally polish off with an old-fashioned moose 
hide polishing point or with Darby's Hard Buff Polisher 
No. 3, used in the dental engine. On this polisher should 
be used oxide of tin or some preparation such as "Carmi- 
Lustro," provided the decay or white decalsification does 
not extend through the depth of the enamel. However, 
more extensive decays just over the juncture of the cementum 
and the enamel on the tooth root often present a leathery 
surface which is very difficult to handle with this protective 
technique. 

The surfaces in the anterior part of the mouth might be 
handled with such substances as nitrate of silver hereafter 
described, but this being a question of position, the next 
best thing is to try the polishing technique. If this leathery 
condition does not extend into the interspaces, we sometimes 
get excellent results by the simple removal of this condition 
and polishing the surface as just described after removing 
this leathery substance. If we find a cavity, now is the time 
to fill it. However, if we reach sound tissue, we should 
have a cup-shaped surface. This surface can be maintained 
in a polished condition and it may not require filling for 
many years. Many times in attempting to operate at this 
point we find an extra sensitiveness," and the patients will 
sometimes say that they would rather have the tooth ex- 
tracted than have you polish this spot. This is the time to 
use the procedure given me many years ago by Dr. Taylor, 
who sprinkled a small amount of powdered cocaine over 
the gum margin, allowing the moisture to dissolve the 
crystals. He advises that the cocaine be used in about the 
same manner as when applying the rubber dam, but cautions 
the operator not to allow the patient to swallow it. Dr. 



Soft Spots and Sensitive Areas. 223 

Taylor used this method for many years without the slight- 
est symptom of trouble. 

One other point which can be used in the treatment of 
these sensitive spots at the gum border, especially after they 
have been cleaned out, polished, and are still sensitive, is the 
application of a small burnisher. 

The patient's head is held firmly, and the hand holding 
the burnisher is held against the tooth which is to be treated. 
Great pressure is applied with up and down motion, being 
careful not to let the instrument wound the gum margin. 
This burnishing should be kept up for several seconds. It 
is remarkable what relief this method sometimes affords, a 
considerable length of time elapsing before the return of 
the sensitiveness. I can give no better explanation of this 
than the answer given by the student who said that this bur- 
nishing "brads the nerve terminals at this point." There 
are undoubtedly irritated and exposed nerve ends, and the 
patient will tell you so when you attempt to do the operat- 
ing. The successful "bradding" in my own mouth on an 
upper bicuspid, where there has been a slight recession of 
the gums, has afforded me the greatest relief of any proce- 
dure which has been suggested or tried. 

In small mouths, I use one of the various cheek distend- 
ers, which not only enables the operator to work with greater 
ease, but also furnishes much comfort to the patient. 



CHAPTER XVI. 

METHODS OF NOTIFICATION AS USED BY 
KELLS, FONES, AND ADAIR. 

Since the whole idea of prophylaxis is founded on regu- 
larity and system, it is well for each dentist to work out 
some individual scheme to carry out this idea. Dr. Smith 
simply telephones his patients once a month. Dr. Kells 
has a list upon which he places the names of all patients at 
their request for regular attention. At stated intervals 
from this list he mails cards as per illustration (Fig. 66). 



DR. 
M 


KELLS WOULD 


REMIND 




that the ti 
their best 
examined. 

1237 Ma 
Phone 


me has now arrived 
care, 


when, 
.teeth 


to insure 
should be 


ison Blanche. 
Alain 1617. 



Fig. 66. Notificatiox Card of Dr. Kells. 



Dr. Kells' idea is that he wants the patients to know that 
he is interested in them, but does not wish to place himself 
in a position of commanding them to come to his office, as 
it might be embarrassing to call a patient who had decided 
to go to some other dentist. The recipient of this card 
is not commanded to come to him, but is just reminded that 
his teeth need some attention and he may go where he 
pleases for this work. 



Methods of Notification. 225 

Dr. Fones mails the patient an engagement card when he 
thinks it time for his teeth to have a treatment. In order 
that he may know whether the patient has received this 
notice or not, he encloses with the engagement card a self- 
addressed, stamped envelope, which contains a second card 
bearing the same date as the notice which is to be signed and 
returned by the patient. (Fig. 67.) 



Dr. 


Alfred C. Fones: 








Your appointment 


card 


for 




June 3d, at 3 P. 


M. 






has been received and 


accepted. 




Signed 







Fig. G7. Notification Card of Dr. Fones. 

If the patient had to telephone his acceptance or write a 
note, Dr. Fones might not be sure as to a definite engage- 
ment. By this system he makes it so easy that the patient 
readily signs the return card, and mails it in the envelope 
already addressed to Dr. Fones. 

Others doing prophylaxis, simply leave it to the patients 
to come in at regular intervals. None of these plans 
seemed to fit my ideas of carrying out this work so I devised 
the following scheme : 

At first, I designated certain hours throughout each day 

for this special work. Mrs. 's appointment was on 

the 10th, and she was reminded the day previous. So on 
down the list. This scattered the work all through the 
month and interfered with regular dental operations. The 
next plan was to bunch all this work into whole days, and 
the organization of what I call my "Prophylaxis Class." 



226 Practical Oral Prophylaxis. 

Certain days in each month were devoted exclusively to this 
work and set aside accordingly. For instance, the second 
Tuesday, Wednesday, and Thursday in each month. After- 
wards I added other days as new patients accumulated. 
(Fig. 68.) 



Second Monday in Each Month 

8:30— Mrs. WM. SMITH 

419 Piedmont Avenue 
'Phone 490 
9:00— MR. FRANK JONES 

43 Peachtree Street 
'Phone 8960 
10:00— MISS RUBY SIMPSON 

76 Johnson Avenue 
'Phone 2442 



Pig. 68. Part of Book for Special Prophylaxis Days, Showing Per- 
manent Engagements for Not Less Than a Year. 



The book used was like an ordinary dental engagement 
book, only the engagements were permanent, and the book 
had only eight or ten pages, each page representing a day. 
By referring to the cut of the engagement book, you will see 
that we knew Mrs. Smith had a permanent engagement 
(Fig. 68). Her time was paid for whether she came or 
not. By adhering closely to these engagements of one-half 
hour each, we found that we could treat from twelve to 
fifteen patients in each of these days. Now having a list 
like this of several days, it was out of the question to phone 
all of these patients every month so I had printed the card 
of notification which is mailed the day previous to the time 
for treatment. 



Methods of Notification. 



227 



A large number of patients to treat, and this work ex- 
clusive for the day, make it very interesting, both to myself 
and the patients. These cards are neatly printed and only 
the dates have to be filled in by the secretary. 

The dav before his first engagement he receives a postal 
card with his dates (Fig. 69). 



SECOND MONDAY IN EACH MONTH 

Dates for Prophylaxis Treatment 

Preserve this Card 

January Monday 10, at 9 o 



clock 



Februarv 
March .'. . . 

April 

May 

Tune 

July 

August . . . 
September 
October . . 
November 
December 
Charge $ 



per year. 

A reminder card will be mailed previous to each date but 
failure to receive such notice does not entitle patient to 
another engagement in the same month without extra 
charge unless failure to be present is due to unavoidable 
cause in which event notice must be given several hours in 
advance. 

The charge for prophylaxis is by the year for twelve 
regular engagements, and is payable semi-annually in ad- 
vance. If for any cause these treatments be discontinued 

before the expiration of contracted time a charge of $ 

will be made for each date up to the time notice is re- 
reived to discontinue. 

Appointments are not to be changed more than three 
times per year. 



Fig. 69. When Patient Engages a Year of Prophylaxis Date-, the 

Secretary Mails to Him a Postal. Card With ALL Date- 

for the Selected Day axd Hour. 



For each succeeding engagement he gets a postal card 
very similar (Fig. 70). 



228 Practical Oral Prophylaxis. 



Your Engagement for Prophylaxis is 

at o'clock 

The charge for this treatment is by the year from date of 
first engagement and is payable in advance. The date 
and hour is fixed, if possible, to conform to con- 
venience of patient and is not to be changed 
oftener than twice a year. 
As this time is reserved, failure to meet engagement results 
in loss to patient and can not be made up unless 
the absence is caused by Providential hin- 
drance, in which event notice must 
be given a day in advance. 



Fig. 70. Several Days Previous to Each Date for Prophylaxis, the 
Patient is Mailed Tnis Card of Reminder. 

The patients should not commence our system of prophy- 
laxis unless they intend to stay at least a year; we enter the 
charge in our ledger for one year, and a bill is rendered 
them for one half, or the whole of the amount. This must 
be paid in advance if this time is to be saved for them. 

At the first appointment, on the record ledger sheet, we 
make a note of all cavities, including the incipient ones, and 
all defects of the mouth. The patient should be made ac- 
quainted with all these conditions and shown the note in 
the dental ledger. At the first treatment the patient must 
invest in two brushes, floss silk, and dentrifice cream, and 
he is taught how to use them. One brush has the name of 
the patient engraved on the handle with a dental bur and 
made plain with a smear of ink. This is kept in the office 
in the formaldehyde sterilizer to be used solely for teaching 
the patient to care for his teeth. The patient, at first, does 
not understand all this business of cards and dates but the 
system keeps up his interest. After the third visit the bene- 
fit is apparent, and the patient is yours to command. After 
years of study and practice this system has been evolved as 
the most efficient method of handling the work. 



CHAPTER XVII. 

METHODS OF NOTIFICATION AND RECORDS 

OF CASES. 

NOTIFICATION OF PATIENTS— RECORDS OF CASES. 
BY DR. JOHN OPPIE MCCALL. 

"These two subjects are considered in one chapter, be- 
cause the two things can be very readily and advantageously 
combined. This is done by having the record chart printed 
on a 6x4 card which is kept in a card index system, and 
which thus serves as the basis of the follow-up campaign, 
so necessary to secure the best results in this field. 

"We will consider modification and follow up first. The 
back of the record chart shown below may be ruled in sev- 
eral ways according to individual ideas. The main thing 
is to have columns for date of appointment, length of time 
consumed, and remarks. The writer does not keep the fi- 
nancial account on this card, and for several reasons. The 
card is to be laid on the bracket table while patient is in the 
chair. It thus serves as a record of past appointments with 
their possible history of delinquency on the part of the pa- 
tient, as well as a ready reference to the pathological condi- 
tions in the mouth. A financial statement forms no integral 
part of such a reference card and is not one of the things 
of which we want to remind the patient, at least while in 
the chair. Appointments for the next sitting may be noted 
on these cards in the presence of the patient, and then be 
checked off when kept. 

"The filing of these cards is not alphabetical, but by 
months (or by days of the month, if so desired). An ap- 
pointment having been kept, the card is filed in the month 



230 Practical Oral Prophylaxis. 

or day of the month when the patient is next to be given 
treatment. As the end of the month is reached, the month 
index card is moved to the back of the file, thus bringing 
forward the cards of those to be seen the following month, 
who will then be notified of the impending visit. Patients' 
cards are only moved back in the file after the treatment. 
Hence at the end of the month the cards of those patients 
who have failed to keep their appointments for any reason 
will be found at the front of the index, and will remain 
there until properly disposed of. 

"The method of notification of the patient will depend 
partly on the patient, but the initiative in making appoint- 
ments can seldom be left to the patient if good results are 
to be had. A notification and appointment card sent by 
mail is usually the best method, although with many patients 
the telephone accomplishes the same end with less friction. 
The patient should be given to understand at the time the 
case is started that the dentist proposes to send an appoint- 
ment. If this procedure does not meet the approval of the 
patient, the matter can be talked over at the time and the 
need of such action explained, thus settling the method of 
notification to be followed for that patient, and avoiding 
possible disagreeable incidents later on. The following is 
the text of the card used by the writer. (Fig. 71.) 



Dr. John Oppie McCall begs to suggest the advisability 
of making an appointment for a prophylactic treatment. 
Experience has shown that short sittings at regular inter- 
vals are necessary, that the improvement secured by pre- 
vious treatment may not be lost. Your case having been 
undertaken, responsibility for its success dictates this 
reminder. 

Time has been reserved for you at o'clock 



Fig. 71. Notification Card Used by Dr. McCall. 



Notification — Records of Cases. 231 

"With this is also enclosed a regular appointment card, 
which can be tucked in purse or pocket to refresh the pa- 
tient's memory. 

"The method of recording pathological conditions has 
been developed on the basis of the needs of the general 
practitioner, but can be used quite as readily in a practice 
devoted to this field. 

"The system was suggested by Dr. A. D. Black, but has 
been considerably modified by the writer. The underlying 
idea is to have a key of numbers or letters, which through 
their various combinations may serve to indicate and diag- 
nose various pathological conditions. 

"The chart shown here is printed on a 5x3 card, but a 
larger one may be used, if desired, with correspondingly 
larger chart. The diagnoses are recorded on it in the spaces 
indicating the location of the conditions recorded, by means 
of three letters which tell the tissue affected, the cause of 
the trouble, and the result shown at the time the examina- 
tion is made. The three letters refer to the three columns 
of the key, the first letter referring to the first column, the 
second letter to the second column, etc. 

"The key letters take up very little room, yet make as 
complete a record as one written in longhand. The key is 
readily memorized, and hence records are instantly avail- 
able. The reduction of records to a key system has another 
advantage; namely, that it is not known to the patient, and 
the dentist is thus spared the necessity of explaining the 
edges of fillings and crowns, etc., for which some colleague 
is responsible, and which may have caused some trouble. 



232 Practical Oral Prophylaxis. 

KEY TO DIAGNOSIS OF PUPAL AND PERIDENTAL LESIONS. 

Pathological Cause Result 

Condition in 

A. Caries A. Active hyperemia 

A. Pulp B. Lack of insulation B. Passive hyperemia 

B. Gum Margin C. Traumatic injury C. Tubular calcification 

C. Pericementum D. Denudation of root D. Secondary dentine 

E. Abrasion E. Pulp stones 

F. Salivary calculus F. Hypertrophy 

G. Serumal calculus G. Stasis 

H. Lack of contact of H. Infection 

teeth, fillings, etc. J. Putrescence (pulp 

J. Improper contact of canal) 

teeth, fillings, etc. K. Pericementitis 

K. Mal-occlusion L. Abscess (incipient) 

(other than above) M. Abscess (with sinus) 
L. Improper margin of N. Recession 

filling or crown O. Denudation without 

M. Improper restoration recession 

of occlusal surface P. Pyorrhea 
N. Mouth hygiene R. Looseness 

O. Systemic disturbance S. Elongation 

T. Bone absorption with- 
out denudation 
U. Sensation 

"Thus ABD indicate a pathological condition of the pulp, 
due to a filling without proper thermal insulation, resulting 
in formation of secondary dentine. BFN indicates a lesion 
of the gum margin due to salivary calculus, resulting in re- 
cession. CKP indicates a peridental affection caused by 
mal-occlusion resulting in pyorrhea. This key can be made 
to serve for quite a complex diagnosis, as for instance in 
the case of hyperemia of the pulp due to denudation of a root 
in the course of a progressing pyorrheal affection. The diag- 
nosis of the pyorrheal condition will be noted as above, and 
the pulp trouble will be recorded thus A.PB, the period in- 
dicating that the last two letters are taken from the last 
column, the one indicating cause of course preceding the 
other. In case two causes are found, as is not uncommon, 
the letters will be included between two periods, as C.JN.A. 
This indicates a peridental disorder due to improper con- 
tact of teeth and improper care by the patient, resulting in 
hyperemic condition. 



Notification — Records of Cases. 



233 



M 



DATE. 







R 






















L 






































































(S 


B 


H 


a 


a 


a 


s 


m 


Q] 


m 


a 


a 


a 


a 


a 


a 


































































EI 


S 


E 


B 


IB 


a 


E 


H 


a 


B 


a 


a 


a 


a 


a 


a 



































































REMARKS: 



AGE 



Fig. 72. Chart B. McCall. 



"On the chart, the teeth are indicated by numbers for the 
upper, and letters for the lower, the same number or letter 
indicating the corresponding tooth on either side of the 
median line. (Fig. 72.) The right upper cuspid is 3R, 
the left lower first molar is FL. Again the key is readily 
memorized, and is the most compact way of designating the 
teeth in recording various operations. The chart shows a 
series of square and oblong spaces which represent the hard 
and soft tissues. The left-hand teeth are found at the right 
of the median line on the chart, this being their position 
in the mouth when the operator faces the patient, and vice 
versa. The little squares containing the number or letter 
represent the occlusal or incisive surfaces and are surrounded 
by a space representing the buccal, mesial, lingual and distal 
surfaces of the teeth. In this space are recorded diagnoses 
of pulp troubles, and also erosion, cavities, etc., of which a 
permanent record is to be kept. It is not intended for a 
record of operations performed. The horizontal oblong 
space at the top of the diagram represents the labial gum 
tissue, and notations in regard to that tissue or the corres- 
ponding peridental membrane are placed in it. The ver- 
tical horizontal spaces under it represent the mesial and dis- 



234 



Practical Oral Prophylaxis. 



tal soft tissues, and the horizontal oblong just above the 
heavy center line indicates the lingual gum tissue. The 
position of these spaces are reversed for the lower teeth. 
See section of chart enlarged." (Fig. 73.) 



fail -XXtxMl^ 



I 



n 



Wr 



■ &**JLiA**fi 






Cca 



tscw*. GC&mA^JL 



Fig. 73. Recording Chart of Dr. McCall. 



NOTIFICATION SYSTEM OF DR. HENRY A. KELLEY. 

"My system of notification is very simple. We will con- 
sider that a patient presents himself for work and we wish 
to get him on to the system of prophylaxis. I give him a 
talk along the lines of preventive dentistry and explain the 
theory of prophylaxis. Having obtained his permission to 
put him on this system I give him a treatment and dismiss 
him, having first inquired as to what days of the week are 
best for him for appointments and what hour in the day is 
preferred. I tell him I will notify him when I want to see 
him again. After he has gone, my secretary first enters him 
upon the list of my patients who are on the prophylactic 
treatment. I tell her how long a time I want to elapse be- 
fore he has another treatment and she turns to my appoint- 
ment book and enters his name as near that time as she can, 
considering his wishes as to day of week and hour. Then a 
few days, say a short week, before the time of his appoint- 



Notification System — Dr. Kelley. 235 

ment my secretary calls him up by telephone and says, 'You 
desired Dr. Kelley to send you an appointment for your 
prophylactic treatment about this time. Now Dr. Kelley 
has reserved the time on such a day and such an hour for 
you. Will this day and hour be agreeable to you?' If he 
says yes, the appointment slip is mailed to him. This must 
be done to avoid the uncertainty of the telephone and to 
impress him with the importance of the appointment. 
Should the time reserved prove to be one not possible to 
him, some other appointment for prophylaxis made for some 
other patient, not yet notified, can be offered and his time 
exchanged with that patient. This is done, of course, as 
the secretary telephones. You will readily see with many 
prophylactic patients on your book you have great latitude 
this way. 

"This is all there is to the system, except, if you have to 
rely upon the mail alone, you must have some system in 
which you get a return answer to your appointment when 
first sent, to know that your patient receives the appoint- 
ment and to prevent loss of time owing to failure of patient 
to receive your appointment when sent. It is impossible to 
fix the blame for this kind of a slip-up and you have to as- 
sume the loss. One thing you have to be careful about, is 
that you do not in some way break this system. Any sys- 
tem is defective in that you may think it is working when it 
is not. So once in a while it is well for your secretary to 
check up the patients that are on the list of those having the 
prophylactic treatment and see that they are all on the ap- 
pointment book somewhere. 

"I believe that the dentist should always look out for 
the patient and should send for him when he thinks he 
should make a dental call and it should not be left to the 
patient to decide when he will call upon the dentist. This 
system of notification for prophylaxis gives you the means 
of educating your patients along this idea." 



236 Practical Oral Prophylaxis. 

SYSTEM USED AND DESCRIBED BY DR. GILLETTE 

HAYDEN. 

"Notification of Patients. — The name, address, and tele- 
phone number of a patient beginning the regular monthly 
treatment are placed on a card, and the card, after having 
the date of the first treatment entered on it, is placed in the 
file box one month in advance of the date of the first treat- 
ment. For example : The patient has the first treatment 
January 3d. The notification card has this date entered on 
it, and is then placed in the file box back of the month card 
of February and date card of 3. On January 31st or Feb- 
ruary 1st the assistant takes all cards bearing date of Feb- 
ruary 3rd, calls each patient by telephone, and arranges the 
hour for the appointment. 

u In every case this has proven the most satisfactory of 
all methods tried. The patients find it easy to arrange 
hours which do not conflict with other appointments which 
they must make, and I find less disturbance from appoint- 
ments cancelled or changed to other dates. Another fea- 
ture of this method is that the appointment book will have 
only two or three days in advance filled completely. This 
permits of opportunities to supply time not too far removed, 
to out of town cases, to emergency and other cases. 

"Out of town patients are notified by mail a week in ad- 
vance that they are due on such date, and that an hour 
(usually that given on the card as the most convenient for 
them) is reserved for them on two different days. They 
make the selection of the day in the reply. 

"Charges. — Charges are made for each treatment. To 
those having an account, statements are mailed every six 
months. 

"Technique of Prophylaxis Treatment. — In the usual 
cases presented each month for treatment the buccal, lingual 
and liabial surfaces of the teeth are reached with S. S. W. 
Scaler No. 3, or 6 and 7 (from set of eight). The mesial 



Notification System — Dr. Spalding. 237 

and distil surfaces are reached with Smith files Nos. 13 and 
14, or Townes Files 33 and 34, or 35 and 36, or with Nos. 
1 to 8 of the Bates' Scalers, according to the size of the 
inter-proximal space and the extent of the recession of the 
tissues. 

The cleansing powder is carried to the tooth to be pol- 
ished on a wedge-shaped orange-wood stick dipped first in 
phenolsodique. A straight large sized orange-wood stick 
is used where the surfaces of the teeth are accessible to it. 
A wedge shaped point carried in the right angle porte pol- 
isher is necessarily used on all surfaces not reached by the 
straight stick. Wherever the loss of the tissues permits the 
use of a small wood point on the approximal surfaces, these 
portions of the teeth are polished in the same manner as 
the other surfaces. 

"Ribbon floss, X size, charged with the abrasive, then 
passed between the contact points and carried up just under 
the free margin of the gum and with a sliding motion of the 
fingers carrying the floss the approximal surfaces are polish- 
ed. With an aseptic dental napkin wrapped about the in- 
dex finger and charged with fine polishing material, the final 
polish is given to the teeth, and a light massage to the gums. 

"A spray containing a zinc chloride solution is used to 
complete the treatment. 

"Sticks are prepared by first sharpening them to a wedge 
shape on a very small plane set (plane side up) in a vise, 
then rounding the corners and smoothing off with sand- 
paper." 

METHOD OF DR. GRACE R. SPALDING. 

"You ask for methods of notifying the patients. I make 
out my appointments at the beginning of each year, and as 
usual there are not many changes because I try to accom- 
modate my patient at first by giving him an hour when most 
agreeable to him. If his work is such that a regular ap- 
pointment is impractical, I call him on short notice when 



238 Practical Oral Prophylaxis. 

I happen to have time for him. The majority prefer, of 
course, to have a regular hour each month. The month is 
considered in four weeks, taking the first Monday, Tues- 
day, Wednesday, Thursday, Friday and Saturday, regard- 
less of date. The first Monday at nine o'clock belongs to 
Wm. E. Smith, Sr., whether it comes on the 1st or 7th of 
the month, as long as it is the first Monday, etc. That 
leaves the extra dates beyond the 28th: at the end of each 
month — 29th, 30th and 31st, for extras and taking care of 
odds and ends if one has or rather wishes to have all of his 
time for strictly prophylaxis work. It is easy for a patient 
to remember, for instance, the second Friday at ten o'clock. 
We send out appointment cards for all appointments in the 
practice, and the dentist's name is sufficient explanation as 
to what the appointment is for, since I do not do any opera- 
tive work." 

In revising this part of the book several dentists were 
asked this question, "What progress did Prophylaxis make 
last year?" The answer of Dr. H. A. Kelley is as follows: 

"The Prophylaxis in which I am deeply interested is al- 
most, if not quite, a fixed science. Of course, there are 
many developments from this Prophylaxis that have many 
new sidetracks, but that is another story. To take a child 
from five years old and so treat him and his mouth that he 
shall be free from dental caries, that is our problem. We 
have to find the man or woman who can so preach the gos- 
pel that the people will listen and believe. When they do 
this, we will show results. See what Wallace has done with 
the fifteen children whose parents he made believe in his 
theories. I am doing some good work with a few children 
in my care. If parents, dentists and children all did all 
they know should be done, we could accomplish much. 

"All that we, as dentists, can do for these children is quite 
simple and very well understood, and not very sensational. 
Therefore, it does not attract attention as the sudden awak- 



Notification System — Dr. Spalding. 239 

ening of dentist and patient to a Pyorrheal condition. How- 
ever, there would be no Pyorrhea in a generation if such 
men as you and I could have our way with the young chil- 
dren, and I venture the prediction that the only cure that 
will ever be found for Pyorrhea is never to allow it to begin. 
"Now, as to any progress in prophylaxis in this narrow 
sense: We have laid down the fundamental principles, the 
mouth must be in order, it must be kept in order. We have 
given a system for keeping the mouth in order. What 
more can we do? I do not see what improvement we can 
make in our system." 



CHAPTER XVIII. 
RESULTS OF PROPHYLACTIC TREATMENT. 

The various arguments brought forward against the 
monthly system of prophylaxis will not have any weight 
with anyone who has observed a patient who has been upon 
this system for a while. Six months treatment will change 
the whole appearance of the ordinary mouth. 

ist, The mucous membrane will assume a normal pink 
color, not only around the buccal surfaces of the upper 
teeth but in every part of the mouth. 

2d, Teeth that disfigure the face can be improved in ap- 
pearance, for, if their surfaces be brought to a high state 
of polish, and the surrounding tissues healthy, one does not 
notice so much their ill shape. 

3d, Many defects in the teeth can be worked out, white 
spots removed, and grooves smoothed out. 

4th, Hypersensitiveness of the cervical margin and irregu- 
larity of the nerves can be corrected. 

5th, Decay is prevented. 

6th, The vital structures within the tooth, and those sur- 
rounding it, especially the peridental membrane, are main- 
tained in normal condition. 

7th, The mouth is safeguarded against violent infections. 

8th, Osseous structures are protected from the irritation 
of deposits and infection. 

9th, Pyorrhea is positively prevented. 

10th, Last, but not least, the greatest result in prophylaxis 
is the aid, training, and maintenance by the patient at home, 
of a perfect dental toilet technique. 

If it were always possible to place the mouth in a per- 
fectly clean condition as to caries and fissures, and the patient 



Results of Prophylactic Treatment. 241 

carried out the instructions for care of the teeth at home, we 
would be able to demonstrate in every case that "Clean teeth 
never decay." Unfortunately this is seldom the case, and 
we are often humiliated in our prophylaxis by the discovery 
of a whiteness showing through the enamel, giving evidence 
of the carious condition underneath. 

It is well to explain to patients, before placing them on 
prophylaxis, in regard to the claim that prophylaxis pre- 
vents decay, that some slight carious condition may possibly 
develop during the first six months or year; that in the inter- 
proximal surfaces, between the molars and incisors, the 
etching of the enamel may have proceeded so far that it 
will be impossible to prevent further decay. It is not al- 
ways possible to find these at once as they sometimes do not 
develop for six months or a year after the patient has been 
placed on prophylaxis. 

In my experience of about ten years in prophylaxis, I 
do not recall, in any of these regular patients, a decay be- 
ginning out in the open, that is, on a surface where it was 
possible to maintain a polished surface. Many teeth with 
deep sulci and grooves may decay in spite of all the prophy- 
laxis you can give them, because it is impossible for the den- 
tist or the patient to keep these depressions in a perfectly 
clean state. It is the best policy to fill these either perma- 
nently or temporarily, as explained in the chapter on tech- 
nique of prophylaxis. 

In regard to the prevention of pyorrhea, I can say that 
in my own experience not one has shown the least tendency 
to this disease. Others who are doing this same work have 
observed the same thing. Of course, this does not take 
into consideration the patients who had pyorrhea at the time 
they began prophylaxis. 

As evidence for my own satisfaction of the fact that pro- 
phylaxis really does prevent disease, I selected pages at 
random from my records, which give the amount of dental 



242 Practical Oral Prophylaxis. 

work required by patients in the five years before they began 
Prophylaxis in comparison with the amount of work they 
have had done since. I included in these statistics such re- 
storative work as fillings and abscesses. For the sake of 
comparison with this, another table was made of dental 
work done for patients of about the same class and mouth 
condition as the patients who had been on prophylaxis. 

These tables show that the patients who have been on pro- 
phylaxis have had little or no dental work done since enter- 
ing upon this system. The second table suggests that, had 
these first-named patients not entered upon a system of pro- 
phylaxis, their dental requirements would have been like 
those named in table No. 2, with their constantly recurring 
dental bills. In addition to this, all these prophylaxis pa- 
tients report fewer doctor bills, and their illness, if any, has 
been light in character; also they have derived much pleas- 
ure from the knowledge that their mouths were in a healthy 
condition and their teeth in a beautifully polished state. Of 
as much interest as all the above results is the pleasure de- 
rived by the operator who sees the accumulative effects of 
his work, bringing unkept mouths into a healthy state. I 
have seen prophylaxis patients so that you could tell them 
across the room, when they smile, by the brilliancy of their 
teeth. Also the satisfaction of having people say, "Why, 

she must be a patient of Dr. , for her teeth are so 

clean looking and pretty." 

The gums of a patient on prophylaxis should become hard 
and pink, and should hug the teeth closely. In other words, 
show a condition of perfect health. The fillings, which or- 
dinarily would show rough margins and surfaces, should 
present the appearance of having just been inserted; and, 
after the patient has been on the treatment long enough, 
all surfaces should exhibit a luster which reflects the light. 



CHAPTER XIX. 

SOME IMPORTANT OBSERVATIONS ON THE 
TEETH AND SALIVA. 

TOOTH ENAMEL. 

Pickerill, and others, who have studied the histology of 
human teeth, have shown that the enamel, as laid down in 
the formation of the tooth, may contain defects, as well as 
fissures, and unclosed rugae. This, of course, favors decay 
by the retention of carbo-hydrates in the form of food 
stuffs, with the final development of micro-organisms. If 
we examine any mouth which is subject to a large number 
of caries, we will find that the enamel contains some break 
on its surface, which defect, while small, is sufficient to retain 
food and allow it to decompose. 

Dr. Head is authority for the statement that the enamel 
of the teeth, which has become decalcified in weak solution 
of lactic acid, or orange juice, even to the point of losing 
its opacity, will be quite restored when subsequently im- 
mersed in saliva for some time. While this seems rather 
hard for us to accept at first, thorough chemical investiga- 
tion seems to bear out this experiment and gives us a clue 
on which to build our future prophylactic technique, and 
mouth wash formulae. There is no doubt that the enamel 
of the teeth varies in structure, hardness, density, permea- 
bility, and solubility, and that we must recognize the fact 
that a large part of this departure from the normal must 
be due to developmental as well as acquired defects. Tak- 
ing this view of the matter, our prophylactic treatment must 
be directed towards the enamel in its formative period in 
order that the proper osmosis of the lime salts -and phos- 
phates shall take place. 



244 Practical Oral Prophylaxis. 

Rose, Bunge, Malcolm, and Pickerill have made exhaus- 
tive experiments in an effort to determine whether or not 
the enamel of the teeth could be influenced by the drinking 
of water heavy with magnesium or calcium salts. Their re- 
sults showed that the structure of the teeth is not influenced 
to such an extent as are the other bones of the body. Their 
conclusions were that the hardness, of the water was not 
naturally or essentially a factor for us to consider. 

ON SALIVA. 

Saliva in the normal mouth varies in character from a 
thin watery consistency, copiously discharged, to a thick, 
ropy, tenacious consistency such as we often see in unclean 
mouths. 

It is unfortunate for the dentist that the analysis of the 
saliva is so complicated. If some simple method could be 
devised so that every operator could make these tests, we 
would probably have some interesting data. 

We know that even so simple a diet as rice will give more 
nourishment than the human system can use and that even 
on this simple diet, the saliva contains its normal amount 
of inorganic salts. Do certain foods exert any special in- 
fluence on this secretion? If not, is it the condition of the 
mouth, teeth, and gums which alters the character of the 
saliva, instead of the food? 

If it were convenient to test the saliva of each patient 
we might have more data on the etiology of the disease, 
and be in a better position to effect a permanent cure. For 
instance an analysis might show an abnormal amount of 
phosphorized fat which would direct our attention to the 
liver. Intestinal fermentation products have been found 
in the saliva, e. g. indican. Auto-intoxication from the in- 
testines may be so great that the kidneys are unable to carry 
off the material, and we may find in the saliva test materials 



On Saliva. 245 

which would direct our treatment toward the establishment 
of a physiological process of metabolism. 

Some writers have endeavored to show that the lessening 
of the quantity of the saliva is responsible for an excessive 
amount of dental caries. So far as I have been able to 
observe clinically, the question of quantity is not of so much 
importance. Recently, I was baffled in the case of a young 
married woman, who, when excited or nervous, suffered from 
temporary stenosis of all the salivary ducts, so that the 
mouth was almost as dry as though she had been taking 
atropin. So great was the pain sometimes caused from this 
condition that the patient became very despondent. As the 
mouth and the surrounding structures were in a perfectly 
normal state, I and my medical associates w T ere at first un- 
able to find any indications for treatment or to afford the 
patient any relief. We began to treat her for a trouble far 
removed, and one which at first we thought had no connec- 
tion with the condition of the mouth, for we supposed that 
getting her mind off her mouth conditions would at least give 
her some degree of comfort. She improved for a time 
under a physician's care but later passed out of our observa- 
tion. The point, however, is that while the patient's mouth 
was dry, she did not exhibit any considerable amount of 
carious condition of the teeth. 

It has generally been noticed that where a pyorrheal con- 
dition is present, we have an increased supply of saliva, yet 
there is often noted a total absence of caries. In the mouth 
of the case described, there was a reduced amount of saliva, 
yet the mouth showed only a small amount of care. My 
observation, while based upon a large number of cases, 
does not allow me to say with any positive degree of cer- 
tainty that caries are influenced by quantity of the saliva, 
still I am of the opinion that the presence of some element in 
the saliva, as well as the quantity of the solution, must be 
looked for as the prohibitive agent. 



246 Practical Oral Prophylaxis. 

Of course, we must realize that stagnation of any secre- 
tion must result in decomposition or putrefaction, and that 
this will contain some degree of infection, but I am forced 
to believe that it does not have as much influence as Pickerill 
would have us think. 

It is a strange law of nature that the quantity of the saliva 
is not increased by the drinking of ordinary liquids. You 
can have the patient with thick, ropy saliva drink large quan- 
tities of water without perceptibly influencing this condition. 
However, stimulants do produce vasomotor effects either as 
a stimulant or a depressant. Tea is given as the greatest 
depressant, while acid fermented liquor, as port wine, pro- 
duces the highest alkalinity index. 

The conclusion which I wish to lead up to is this. It does 
not matter what the condition of the saliva is, nor the quan- 
tity, nor the quality. What we are most interested in is to 
note that the patient with an abnormality of the saliva has a 
much better chance for a return to the normal or the phys- 
iological condition when on regular prophylaxis. 

Pickerill has made considerable study of the composition 
and behavior of the human saliva, and from his writings 
we have the following deductions : On the degree of excita- 
bility of the various glands which furnish the saliva, he has 
found that the ordinary tasting of foods does not excite the 
glands to action and that "bread and butter depress the se- 
cretion." In his table of experiments from bread and but- 
ter at 1.73 alkalinity per minute, he runs the list of pine- 
apple, cake, grapes, celery, meat, stewed apples and up to 
lemon juice which is 6.24. Also, it is shown that the alka- 
linity of the parotid saliva is greater than that of the other 
glands, although these glands furnish only a small quantity 
of the secretion. It is a most beautiful and wonderful pro- 
vision of nature that, whatever the degree of acidity in the 
food products, the proper alkalinity is furnished by the sa- 
liva, although the acid food may be so strong that it could 



Sulpho-Cyanide of Potassium. 247 

etch the enamel surface of the teeth, as in the case of the 
Silesians, who suck lemons for a pastime. The after flow 
contains sufficient alkali to neutralize the acid, and the 
question of alkalinity is one of the most important with 
which we have to deal. 

PTYALIN. 

Physiologists teach us that the action of ptyalin in the 
saliva is for the purpose of converting the starch into sugar, 
in order that the sticky or solid material may be changed 
into one soluble and ready for absorption. We are led to 
believe that ptyalin has more to do with mouth conditions 
than this. 

The operation of extirpation of most of the salivary 
glands has not resulted in any difference in undigested starch 
products. In order to prove this, Pickerill selected two rab- 
bits, A and B. One was kept as a control while the other 
one had the parotid and submaxillary glands on both sides 
removed. Weeks after the operation feces were collected 
at intervals, and the examination showed no difference or a 
very small difference of undigested starch. Pickerill sug- 
gests that the function of ptyalin is not as heretofore sup- 
posed, but rather, for acting upon the carbohydrates re- 
maining, or debris left around the teeth, to be used after 
the process of digestion in the intestines has gone on. 

SULPHO-CYANIDE OF POTASSIUM. 

Another substance in the saliva which has been the sub- 
ject for much speculation is sulpho-cyanide of potassium. 
Some thought that by increasing its quantity we would gain 
some protection against caries, and yet, Ellenberger and 
others have demonstrated that this substance is not found 
in many animals which are immune to caries. Some au- 
thors, as Neuchael, Lowe, Beech, and Geyger, are of the 
opinion that some salt of this substance, administered inter- 



248 Practical Oral Prophylaxis. 

nally, might in some way produce an inhibitory action on 
dental caries. However, Miller and Kirk have exactly the 
opposite opinion. About all we know is that a weak solu- 
tion of sulpho-cyanide of potassium possesses slight anti- 
septicr qualities. Experiments show that the percentage of 
this drug in the saliva can be increased by the internal ad- 
ministration of one fourth of a grain daily, and the sug- 
gestion is given to try this in those cases where children's 
teeth are being destroyed by caries. It is doubtful whether 
any direct good will result but it appears to be worth giving 
a trial. 

PHOSPHATES AND CHLORIDES. 

Phosphates and chlorides undoubtedly increase our de- 
sire for a certain class of food and drink. For instance, if 
we rinse our mouths with a mild solution of sodium chloride 
we are enabled the more readily to taste sweets. 

MUCIN. 

This substance seems to have only the function of a lubri- 
cant or protective covering for the mucous membrane. Un- 
fortunately, it is also precipitated around the teeth and, in- 
stead of being a protection, forms various kinds of plaques. 
Into this precipitation is caught the food products which in 
time cause the development of caries. 

POSSIBLE PRESENCE OF IMMUNE BODIES IN THE 

SALIVA. 

Miller suggests that phagocytes or protective bodies may 
be present in the blood. However, the presence of phag- 
ocytosis has not yet been established. If this is ever done, 
it is possible that opsonins in the saliva and the raising of 
this index will become just as potent a factor in dental pro- 
phylaxis as it has proved in raising the immunity against 
certain diseases. 



Presence of Immune Bodies in Saliva. 249 

The result of all this investigation gives us very little 
knowledge which we can use in our work of preventing de- 
cay. This much we do know, that organic acids increase the 
alkalinity of the glands, and, conversely, neutral salts pro- 
duce diminution of the protective substances which we wish, 
and that if we remove oral sepsis, by a system of prophy- 
laxis, the saliva can be made one of the greatest aids in 
keeping the teeth clean, because, in a proper condition, it 
acts by constantly washing the teeth and surrounding parts, 
giving the patient the most ideal mouth wash, nature's own 
make, which formula has not been equalled. 



CHAPTER XX. 
TRAINING OF FEMALE ASSISTANT. 

TIME FOR INSTALLING ASSISTANT. WHERE TO SECURE BEST 

HELP. OFFICE TRAINING FOR THE POSITION OF 

DENTAL NURSE. 

TIME FOR INSTALLING ASSISTANT. 

When the author first came to Atlanta fifteen years ago, 
there was only one white female assistant in a dental office; 
several dentists had negro girls. Shortly after this some 
of the dentists began putting white girls into their offices but 
were criticised for it. To-day, such a revolution has come 
about that every office of any reputation has from one to 
three young ladies employed. Even the term "office girl" 
has now disappeared, and each young lady has her special 
duties to perform, and is entitled to the name of assistant, 
secretary, bookkeeper, or dental nurse. 

To the student who is soon to start a practice, to the 
young man already graduated, or to the older practitioner 
who has not availed himself of this great help, these pages, 
I hope will be of assistance. 

The first question which naturally arises when the subject 
is brought up is, "When should such help be installed?" 
In answer to this, I should say that just as soon as the office 
is established, and the patients begin to make their appear- 
ance, then should the training of the assistant begin. In 
other words, I consider the trained female assistant just as 
necessary to the dental office as the chair or the engine. 

WHERE TO SECURE BEST HELP. 

The next question is, "From what source is such a girl 
to be obtained?" The advice that I give my students in a 



Where to Secure Best Help. 251 

rather semi-serious mood is that they insert in the daily 
newspaper exactly the description of the girl they desire, 
withholding, of course, their own name and address; the 
office will probably be flooded with applications. If they 
meet these pleasantly, they have placed an advertisement in 
just so many homes from which they may receive future pat- 
ronage. 

The scheme, however, which I employ, is to go to the 
floor-walker in some department store and explain to him 
exactly my needs. My reason for this is that in his daily 
watch over a large number of young ladies, of the class from 
which we must employ the ordinary dental assistant, he has 
the chance to pick out the one to suit the position. If you 
explain to him that it is a regular position, and one where 
advancement can be expected, he will frequently tell you of 
some young lady in his employ, with whom, for the sake of 
allowing her to take the better position, he is willing to dis- 
pense, or, if he is not so inclined, he will generally tell you 
of some one, formerly employed by him, who will come up 
to the requirements. I have always found the girls endorsed 
by the floor-walker to make better employees than those 
secured from other sources. I have also found that appli- 
cants from newspaper advertisements and employment bu- 
reaus have often not been able to furnish the proper refer- 
ences. 

In making your decision as to the fitness of an applicant 
investigate her references. If she can give the pastor of 
her church, you may generally put it down that this counts. 
Always prefer one who lives at home, or with her relatives, 
or one who can give good reasons for not living at home. 
Give the preference always to the older applicant, other 
things being equal. The girl under nineteen years of age 
has no place in the dental office. 

One thing that must be guarded against is the good look- 
ing girl. In my own experience, as well as that of others, I 
find that such a girl is not the proper applicant for the posi- 



252 Practical Oral Prophylaxis. 

tion of dental assistant or nurse. Not that beauty itself is 
a detriment, but rather, it is of such charm that you will 
either have your patients talking about the good looking 
girl in your office, or it may soon lead to her taking a mat- 
rimonial venture and your assistant is lost to you as soon as 
she is trained. 

Explain to the applicant that it will take several years of 
training before she can expect any considerable advance of 
wages. From the very first, it is best to have this under- 
stood. I have noticed that the dentist who employs a young 
lady and fails to have this understood at first, soon finds that 
the girl is trying to run the whole office. He has made so 
many promises that her wages have to be increased before 
the dentist's income is sufficient to warrant it. 

The first duty of the female assistant to the dentist is that 
she, being a good housekeeper, keep his office in order. 
This must be understood before she enters the office as as- 
sistant. No matter what her qualifications are, if she is not 
willing to go into the office, and, if needs be, scrub the blood 
from the floor after an operation, she is not the one for him. 
She must be willing and able to keep the office in order and 
in a clean state for, although our buildings have janitors, 
they do not clean the cabinets and wash stands. Many times 
she will be called on to clean the basins and the spittoons 
after a bloody operation. 

The young lady should be given a key to the office, and, 
at least half an hour before you arrive, should open up the 
office, dust it, and turn on the heat. In other words, have 
everything ship-shape on your arrival, so that without fur- 
ther delay you may proceed with the patients. 

In regard to her dress, I would advise that you make 
some distinction or difference from the ordinary dress. Now 
this will have to be understood at the time she takes the 
position for, if you wait several months, you will find that 
she is not willing to change. Many girls of this class wear 
gaudy jewelry and gay costumes. You will have to explain 



Where to Secure Best Help. 253 

to them that they are in the same position as the trained 
nurse and must wear simple clothing. It is better that she 
wear nurse's costume or some part of a nurse's uniform. 

If you have secured the services of the proper young 
lady, and you can not secure this proper applicant on a salary 
of less than $6.00 per week, this amount will be well spent, 
and she can save the dentist's time, and time is money to a 
dentist. In addition to this, she is in a position to add to 
your reputation, because she will talk your business better 
than you can yourself. 

As the majority of dentists do not employ but one young 
lady, I will describe some of her probable duties which she 
will have to perform and in which she can be of real assist- 
ance to the operator. It will be best not to try to teach her 
the names of the instruments the first week, but try to teach 
her the use of the telephone. I would suggest that the den- 
tist himself not answer the telephone at all. Dr. Kells, for 
example, will not answer his telephone during office hours. 
There is a good reason for this. These telephone messages 
are often for the purpose of breaking an engagement, ob- 
jecting to an account, or complaining about work. In mak- 
ing engagements over the phone, you are never able to tell 
just how much time to leave out for such and such an opera- 
tion. It is much better for the patient to come to the office 
for an examination. This engagement can be made by the 
assistant. It is a great advantage to have provided a special 
telephone record. The sheets should be about 6x8 inches 
and padded. One sheet should be used for each day. The 
assistant should accurately record in one portion of the sheet 
all incoming messages. On another section all outgoing 
messages. Thus the dentist may know at the end of the 
day what has gone on over his phone without being bothered 
all through the day. At the end of the day he may sit 
down at his leisure and attend to each call. When the as- 
sistant makes engagements, I would suggest the following 
line of conversation: 



254 Practical Oral Prophylaxis. 



"Yes this is No. Dr.- 



office. What name, please? Yes, he is here, but engaged 
in an operation. It will be a favor if you will give me the 
message as I make engagements for him." The reason for 
this line of talk is that it impresses the patient that you are 
busy. If the person at the other end of the line refuses to 
give the message, the following reply should be made, 
"Leave your number and I will have the Doctor call you 
later." If the message is delivered, it should not be de- 
livered to you verbally but written on a slip prepared for 
phone messages. This gives you time, also, to frame the 
proper answer. If an engagement is to be made, the en- 
gagement book is taken to the telephone. If a bill is in 
question, you may take the ledger to the telephone with you. 

Have it distinctly understood that your telephone is for 
business, and not for the young lady to talk to her gentle- 
man friends, for some day while such a flirting conversa- 
tion is going on, a patient suffering with a toothache will 
call some other dentist, not being willing to wait until the 
conversation is over. 

It is best to have the assistant make all engagements 
which must be recorded in an engagement book. If made 
over the telephone, it should be verified immediately by 
mailing a card to the patient. This will save many lost 
hours. 

She can make all bank deposits. She should be instruc- 
ted how to write a receipt and to receive money from pa- 
tients while you are busy. 

She must be instructed how to handle the patients in the 
parlor, especially the waiting ones. She must be able to 
explain to them that the doctor is engaged in a difficult op- 
eration, and, in justice to the other patient, they must wait 
patiently. There is one thing which she must not talk about 
and that is what is going on in the operating rooms. She 
must be, so far as talking to the patient on this subject is 
concerned, a blank. Especially will she be questioned as to 



Training a Dental Assistant. 255 

the Doctor's fees. SJie is supposed to know nothing along 
this line. 

As I have said, she must be a good housekeeper. It 
should be her duty to see that the janitor sweeps down the 
walls, that the mirrors are polished each morning, that the 
laundry is not full of holes, and that it goes out regularly 
and comes in on time. She should have the purchasing of 
the towels, napkins, and linen, as she knows more about 
such things than the dentist. One of the hardest things, I 
find, is to get the assistant to keep an accurate laundry list, 
and I consantly find myself buying a new supply of linen. I 
find it a good plan to buy ordinary duplicate order books, 
and insist that the quantity of each article be put down, and 
that a duplicate sheet be put with the clothes ready for the 
laundry, then, that this slip be checked before receiving the 
clean linen. 

If she is to be of value in assisting around the chair, she 
should have the quality of seeing ahead, that is, of antici- 
pating the needs of the dentist. In other words, the den- 
tist should not have to tell her everything to be done. The 
minute the patient sits down, she should put a protecting 
napkin around his neck, and place a cup of some antiseptic 
mouth wash near at hand. She should see to it that the 
chair is comfortable. This done, she should step aside. 

I have found it better not to keep up a line of conversa- 
tion with the assistant. If a code of signals can be arranged, 
\ou will find it of advantage, for, sometimes, you will want 
her to go out, and to tell her to go would defeat your pur- 
pose. One tap of the instrument could mean for her to 
stay, two for her to retire. 

One of the most valuable adjuncts to my office is the use 
of a card, as shown below (Figure 74) . As soon as patients 
arrive they are furnished this card by my female assistant. 
She sees that it is properly filled out before bringing it to 
operating room where it is placed in a special holder just 



256 Practical Oral Prophylaxis. 

next to my cabinet, without disturbing me, yet where I can 
see the full significance of the waiting caller at a glance. 



KIND] 

Name 
Ac 

Wishes 
O 
O 
O 
O 
O 
O 
O 

Memor 


_Y WRITE NAME AND ADDRESS 
AND CHECK YOUR CALL 


idress 


to see 

Dr. Robin Adair 

Prophylaxis Assistant 

For Examination (Fee $1 to $5) 
To make engagement 
Have engagement 
Business call 
Social call 

andum . 








1 


2 3 4 5 



Fig. 74. On arrival callers are furnished with this card by the sec- 
retary. As soon as filled out, the card is placed in a special holder 
before the proper operating chair. 



This enables one to know the caller's name and address, 
saves introduction, and a lot of questions. If the check is 
on second item, then the assistant malj^s the engagement 
without disturbance. I have never yet had a book agent 
check anything except the business call, and all of these 
checks are requested to call after office hours. The numbers 
at the bottom denote the number of patients waiting before 
the last one came in. This card enables the assistant to 
handle a large number of callers without disturbing the 
dentist. 



Office Training for the Nurse. 257 

At the end of the day these cards are taken and all work 
done for each is figured out. I have their correct address 
which may be new since my last work. 

Other duties for a female assistant are suggested under 
the head of Dental Nurse. Many of these can readily be 
taught to the average female assistant. 

If, perchance, you can employ a young lady who is a 
stenographer and bookkeeper, you are indeed fortunate, for 
there is nothing more needed in the modern dental office 
equipment than careful work along this line. While you 
will have to make the original entries of work done at your 
chair, she can afterwards record them in the dental ledger. 
At the end of the month, she can save you a great amount 
of time by making out the statements. 

I have always found that a young lady, calling up a pa- 
tient for a delinquent bill, saying that she is bookkeeper for 

Dr. , and that it is time for closing up the books, 

and she, finding that the bill had not been paid, would like 
to send around for it, does more good than putting a lawyer 
after them. 

Some dentists have their bookkeeper look up the financial 
rating of a new patient when he first presents himself, so 
that she can hand the dentist, written on a sheet of paper, 
just what to expect in the way of payment. Even the in- 
formation given by the city or telephone directory is most 
valuable at this time. 

OFFICE TRAINING FOR THE POSITION OF DENTAL 

NURSE. 

If the dental nurse has been trained up from the dental 
assistant, she probably knows the patients and has their con- 
fidence and you will have less trouble in introducing this 
line of work into your practice. It is to be hoped that by 
the time this book is published, some school will have taken 
advantage of this opportunity by putting into its curriculum 
a course of training for dental nurses. As the question will 



258 Practical Oral Prophylaxis. 

be taken up more fully in the latter part of the chapter, it 
suffices for the present to give some suggestions to those 
who wish to train their own assistant for prophylaxis. Some 
simple rules may be of help; in the first place, it will not be 
advisable to call the assistant a dental nurse until she has 
had a degree of training and has become somewhat efficient. 
The first qualification is that she have some aim in life, and 
be of settled disposition, for the girl whose future is in 
doubt has no place in this work. 

I would begin the training by placing at her disposal some 
of the simple books on sterilization as given for general 
surgery. She should be first aid in minor surgical work and 
should assist the dentist in administering anesthetics. In 
the first place, it is an absolute necessity that the assistant be 
present when giving an anesthetic, and that she be taught 
along this line, for many is the time that the assistant gets 
excited more than any one else. I would let them read the 
small book of lectures by Dr. De Ford. In this way, they 
will receive the knowledge of what is expected of them un- 
der such circumstances. 

The anesthetic having been determined upon, if the pa- 
tient is a woman, the dentist steps from the room and 
leaves the patient in the hands of the nurse. The nurse 
sees that the corset is either loose or removed, the tight 
collar and the neck band opened. The dental nurse can at 
this stage dispel the fear from the mind of the patient 
better than the dentist. She should put around the patient 
the protecting apron and have a hand spittoon within reach 
and a supply of towels convenient. She should be taught 
how to proceed in the case of an accident for, if she is not, 
she may desert you at a critical moment. 



CHAPTER XXI. 
THE DENTAL NURSE. 

VIEWS OF FONES, MERRITT, HYATT, HART, EBERSOLE, NO- 
DINE, KIRK AND SKINNER. AN ACT TO REGULATE 

THE PRACTICE OF ORAL PROPHYLAXIS BY A REGIS- 
TERED DENTAL ASSISTANT. THE MASSACHUSETTS 

DENTAL SOCIETY BILL. 

The trend of the times is toward trained dental assistants 
for oral hygiene work. Women now employed in this oc- 
cupation have been designated dental nurses. In many of- 
fices they are successful in the field of prophylaxis, in the 
schools they are doing great work in the examination of 
children's mouths, and in the various clinics instituted in 
some countries they have proved superior to men for all 
work. 

In order to show the present demand for dental nurses, 
the author has selected from the published views of some 
of the leading men in our profession, quotations on the sub- 
ject which are given at some length. 

Dr. A. C. Fones says: "A busy practitioner can not 
comfortably do this work alone, unless he limits the num- 
ber of his patients to comparatively few. He must have 
aid, and I believe the ideal assistant for this work to be a 
woman. A man is not content to limit himself to this one 
speciality, while a woman is willing to confine her energy 
and skill to this one form of treatment. A woman is apt 
to be conscientious and painstaking in her work. She is 
honest and reliable and in this one form of practice, I think 
she is better fitted for the position of prophylactic assistant 
than is a man." 



260 Practical Oral Prophylaxis. 

This view is also taken by Dr. A. H. Merritt : 

"It is an innovation that has been made necessary by the 
evolution of dentistry. It is in the line of progress and will 
prevail. It may not come this year or next, but that is of 
little consequence, it is enough, just now, to know that it is 
a part of the dentistry of the future. Like all forward 
movements it may meet with opposition, and that from those 
most directly benefited, but that is to be expected. Progress 
has always been made in the face of opposition. 

"In the very nature of things it must go forward, and 
co-operating with it to the end that the public shall be better 
served will go to the trained dental nurse." 

Dr. T. P. Hyatt takes up some of the various objections 
which have been raised against this movement: 

"The work of the nurse is to keep all the exposed sur- 
faces of the teeth in a high state of cleanliness and polish. 
Please understand that when I say polish I mean the kind 
that is secured by the methods advocated by Dr. D. D. 
Smith. 

"I shall make no attempt to show the need of dental 
nurses in our dental dispensaries or schools, for the reason 
that once they admit their need in our offices, it must follow 
that the need is great and greater in the dental dispensaries 
and schools. 

"Up to the present I have only heard three objections to 
passing laws permitting dental nurses, which laws would 
regulate the knowledge required, and prescribe the rules and 
regulations under which they should work. 

"ist, If you want a dental nurse take a graduate dentist. 

"2d, If this work is so important it should only be per- 
formed by a college graduate holding the dental degree. 

"3d, To allow any one other than a doctor of dental 
surgery to perform any service in the month is to lessen the 
value and importance of our work. 

"What work is the dental nurse expected to perform? 
To fill teeth? To make crowns or bridges? To cut, or re- 



The Dental Nurse. 261 

move any of the normal structure, such as tooth structure, 
gum or alveolus? To treat pathological conditions and pre- 
scribe drugs? If any or all of these are required or ex- 
pected of the dental nurse, then they should be graduated 
doctors. 

"Those advocating dental nurses do not expect any of 
these things. 

"Does any one question that the work a trained nurse 
does is important? The health, even the life of the patient 
depends upon the performance of these duties regardless of 
who does them. Their importance being admitted, with the 
realization that the success of an operation depends upon 
their being done, and done right, does the medical profes- 
sion insist that only graduated doctors, or women who have 
secured the degree of M.D. be permitted to perform these 
important services? 

"Another objection I have heard and with due reprise 
and astonishment that any one for a moment can believe 
that it is really worth considering at all. The objection is 
this: If we allow young women to become trained dental 
nurses, a great many might start dental offices of their own. 
It seems absurd to think that anyone could advance such 
an idea with any seriousness. 

"Dental nurses will be of such inestimable benefit to the 
public, our patients, and to the uplift of our profession, that 
all good men should unite, and think out, and work out the 
best and safest plans for its accomplishment." 

Dr. Chas. E. Hart, of San Francisco, says in reference 
to the dental nurse: "I have two with me at present and 
am running two operating rooms. The uniforms that cos- 
tume the nurses are made of white material and of similar 
substance to the ordinary surgical gown, and made up in 
simple form with pattern to suit the person." 

Dr. W. G. Ebersole, of Cleveland, says: "I find the 
lady graduate for prophylaxis work to be very satisfactory 



262 Practical Oral Prophylaxis. 

indeed. This is the beginning of the ninth year in which T 
have employed ladies in this field." 

Dr. A. M. Nodine, of New York, suggests that: "It 
would be a mighty fine thing for the dental profession to 
achieve this accomplishment for the benefit of the millions 
of poor school children. If the public wake up to the real- 
ization of the possibilities, importance, economy and prac- 
ticability of the idea, it will establish the trained nurse in 
spite of either the apathy or protest of the dental profes- 
sion." 

Along the same line of prophecy, Dr. Kirk, by editorial 
in Dental Cosmos, says : 

"Whatever objections may be urged at present against 
the employment of the dental nurse in the capacity here 
under consideration, the trend of the time appears to be in- 
evitably in favor of such a course, and it is highly probable 
that the near future will see the dental nurse as firmly in- 
trenched in her field of activity and as efficiently serviceable 
therein as to-day we find the usual lady assistant in our 
modern dental offices." 

I can not for the life of me see why the dentist will un- 
dertake even the operation of filling the teeth without first 
using the precaution of cleaning the field of operation. I 
have made it a rule in my office that before I take the pa- 
tients, I turn them over to my dental nurse, who, if nothing 
more, mops and syringes the mouth out with antiseptic solu- 
tions. I find that the patient appreciates the work more 
and that it lasts longer, and, surely, it is more pleasant to 
work in a clean mouth than in a dirty one. Then too, when 
I have finished the work for the patient, he is again turned 
over to the nurse, who suggests the proper toilet articles 
such as dentrifice, silk, mouth wash, etc. If the patient de- 
sires, these are furnished him before leaving the office. 

It is a good idea to keep these things for sale in the office, 
as it gives the nurse a chance to earn part of her salary. It 
also gives the nurse the opportunity of instructing the pa- 



The Dental Nurse. 



263 



tients in the manner of brushing their teeth. Few patients 
know this, and the dentist is too busy to show them properly, 
as it takes some fifteen or twenty minutes. 

You will find in the case of the younger patients, that if 
they had to be led in to you first, would probably be afraid 
and hard to manage. The dental nurse can take these chil- 
dren for a few sittings and, by cleaning up their teeth and 
teaching them something about oral hygiene, will be able to 
turn them over to you, with all fears dispelled, for the fur- 
ther treatment of their teeth. 




Fig. 75. A neat gown to be worn by the female assistant. This lady 
was Mrs. Irene Wood, who for many years practiced prophylaxis in the 
office of the author. She cleaned the teeth of so many visiting den- 
tists from other cities that she was the recipient of invitations from 
several associations to read papers and specially by clinic and demon- 
strate her method of handling children. Mrs. Wood was probably the 
first real dental nurse in the South. 



264 



Practical Oral Prophylaxis. 



Women are particularly adapted to the work of prophy- 
laxis in that the sense of touch is more delicate, and, just as 
they are willing to spend hours working on a small hand- 
kerchief, so they will be willing to work for a long time re- 
moving stains from teeth while the dentist devotes his time 
to other work. 

There are many patients who would avail themselves of 
the opportunity for prophylaxis, but who are not willing to 
pay a dentist for his time. Thus the dental nurse enables 
these to have this treatment at a smaller fee, as the dentist's 
time is worth from $5.00 to $10.00 per hour, the nurse's is 
worth from $1.00 to $5.00 per hour. She can spend more 
time than if the dentist did all the work himself. In the 
course of time, the patient begins to appreciate this class of 
dental work, and will be willing to pay regular fees. 

Several years ago when I first determined to train a nurse 
for some of my work I advertised, and talked with 150 
applicants before I accepted a middle-aged trained nurse 
who for many years did the larger part of this work in my 
office. She first helped me at the chair, then took a course by 
reading everything published on the subject; she also brought 
in her kinsfolk's children and her friends to practice on. On 
regular patients I would do the difficult part and have her 
finish the treatment. Thus she became proficient and self- 
confident, while the patients were delighted with the novelty 
of the idea. (Fig. 75.) 



DR. ROBIN ADAIR 

RESPECTFULLY ANNOUNCES TO HIS PATIENTS 
THE SERVICES OF A TRAINED DENTAL NURSE 
TO PRACTICE ORAL PROPHYLAXIS UNDER HIS 
DIRECTION AT A MINIMUM FEE. 

THE TRAINING OF CHILDREN IN THE PROPER 
CARE OF THEIR TEETH HER SPECIALTY. 

Phone Main 2442. 



Fig. 76. If you employ a dental nurse or hygienist, this card given to 
your patients is efficient. 



The Dental Nurse. 265 

A card was sent to all my patients to let them know about 
the dental nurse. (Fig. 76). When I saw she was a 
success I quit the work, except to those who were willing to 
pay well for my service, and sent out, as "per suggestion by 
Bro. Bill," another card. (Fig. 77.) 



DR. ROBIN ADAIR 

RESPECTFULLY ANNOUNCES THAT ON DECEM- 
BER THE FIRST HIS FEES FOR ORAL PHOPHY- 
LAXIS WILL BE ADVANCED. 

November 26, 1909 



Fig. 77. When an assistant is employed for prophylaxis, your fees 
should be advanced in order to put this work in his or her hands. 

In regard to the dental nurse I can only say that when the 
proper help is secured it not only adds dignity to the dental 
office, but also enlarges the field of the dentist. 

The dental profession has become so divided on this 
question that no law has yet been passed, but it must be the 
final solution of the great problem of oral hygiene. 

Dr. H. S. Seip,. president of the Pennsylvania State Den- 
tal Society for 19 14 says in his address, "Owing to the 
mighty movement of oral hygiene, as to the inability of the 
dental profession to take care of the pressing necessity for 
the treatment of dental caries and irregularities, I recom- 
mend a change of our dental laws, so as to provide for the 
licensing of the dental nurse, who shall assist the dentist, 
and who shall also be permitted to give prophylactic or 
surface treatments of the teeth, etc. Suitable course of in- 
struction could be provided by the dental colleges, and the 
services of these nurses utilized while they are taking the 
course at the chair and clinic, as are the services of the med- 
ical clinic at our different hospitals." 

To those who contemplate taking a stand for the legal 
status of female dental assistants the following suggestions 
were given by Dr. F. H. Skinner, of Chicago, after a 



266 Practical Oral Prophylaxis. 

lengthy conference with him on this subject. In view of the 
fact that we have no institution where instruction is given 
the nurses he gives a plan whereby they may be trained and 
legalized. 

AN ACT TO REGULATE THE PRACTICE OF ORAL 

PROPHYLAXIS BY A REGISTERED DENTAL 

ASSISTANT. 

(by f. h. skinner, d.d.s.) 

requirements for application. 

i. Application for license must be made to the State 
Board of Dental Examiners, and signed by a regular regis- 
tered dental practitioner. 

2. Party for whom application is made must be twenty- 
one years old and graduated from an accredited high school. 

3. Said party must have had at least three years expe- 
rience as a dental assistant under a licensed dental practi- 
tioner who vouches for applicant's efficiency and a certain 
knowledge of the few drugs and medicines used in oral 
prophylaxis. 

License. 

Upon such application being presented to the State Board 
of Dental Examiners, that body, at its discretion, shall issue, 
or cause to be issued, a license permitting the party named 
to practice oral prophylaxis only in the office of the prac- 
titioner who signs the application, or such place as he may 
request. (As a call at a home to give an oral prophylaxis 
treatment, in case of sickness.) 

The State Board has a right to satisfy itself as to the 
qualifications of the applicant, as to the education, age and 
character, as well as by examination as to ability, and if 
deemed advisable, require applicant to give a clinic to sat- 
isfy itself, or it may issue license solely upon the reputation 
of the dental practitioner who signs the application. 



The Massachusetts Bill. 267 

Fees. 

The fee for said license shall be $10.00 (ten dollars) and 
shall be subject to the same registration and fees as the 
license of a practicing dentist. 

Should the party to whom license is issued leave the em- 
ploy of the practitioner who signs the application, said 
license becomes null and void, but a new license may be 
issued without examination should the party enter the em- 
ploy of another dentist. The object of this is to have this 
work done always under the supervision or control of a reg- 
ular dental practitioner. 

THE MASSACHUSETTS DENTAL SOCIETY BILL. 

A committee from the Massachusetts Dental Society 
drew up and presented a bill for legislative enactment giving 
a legal standing for the dental nurse and the methods of 
control. The object of this bill was thus urged by the com- 
mittee: 

"The object of the bill is to secure for the dental profes- 
sion the help in practice furnished physicians and surgeons. 
By our present dental law the dentist can not legally have this 
needed assistance. Even the registered nurse while doing 
work among the poor, can not examine the mouth of a child 
suffering with toothache and put in anything to relieve the 
child's distress without breaking the dental law. So slight 
an operation as tying a piece of silk or putting a piece of 
tape between teeth for wedging, is illegal when not done by 
a registered dentist. No one but a registered dentist may 
clean or polish teeth. This makes it impossible for chil- 
dren's teeth to be properly cared for, as the busy dentist 
can not devote time enough to this operation, and in order 
to have it done as often as needed, it becomes a financial 
burden for a family of limited income at the price a regis- 
tered dentist must charge for his time. In the public clinic 
the registered dentist can do practically nothing in polish- 
ing the children's teeth. 



268 Practical Oral Prophylaxis. 

"The prophylactic care of children's teeth is therefore 
not practicable with our present legal conditions. In order 
that the children may have this proper care, the public needs 
a dental nurse. This nurse need not have at present the 
extended training that is given a registered nurse. The 
training that she will receive in the training schools will give 
the dental profession a standard of service that we have 
never had. There are many young women employed in the 
dental offices of our State who by being trained and being 
registered as dental nurses would be of invaluable aid to 
their employers. No one need, however, employ such a 
nurse. The regular office assistant will be used as formerly, 
only she may not do the things the registered dental nurse 
may do, and of course she will lack the training." 

A new Dental Practice Bill (191 5) has been signed by 
the Governor of the State of Massachusetts. This Bill is 
of great interest to those who are working for legal recogni- 
tion of the Dental Nurse or Dental Hygienist. This part 
reads: 

"Any person of good moral character and twenty years 
of age may, upon the payment of ten dollars, which shall 
not be returned to him, be examined by said board in the sub- 
jects considered essential by it for a dental hygienist, and if 
his examination is satisfactory, shall be registered as a 
dental hygienist and given a certificate allowing him to clean 
teeth under the direction of a registered dentist of his com- 
monwealth in public or private schools or institutions ap- 
proved by the local board of health." (Bill No. 228, Sec- 
tion 3, lines 43 to 62.) 

As a matter for record and to give suggestions for those 
who may in the future wish to propose legislation on this 
subject the defeated Massachusetts Bill of 19 12 is printed 
in full. 



The Massachusetts Bill. 269 

HOUSE .... No. 1566 

The Commonwealth of Massachusetts 

In the Year One Thousand Nine Hundred and Twelve. 

AN ACT 

To amend the law regulating the practice of dentistry. 
Be it enacted by the Senate and House of Representatives in General 
Court assembled, and by the authority of the same, as follows: 

Section i. Any person who is eighteen years of age or over and 
in the opinion of the Board of good moral character, upon payment of 
a fee of five dollars, which shall not be returned to him, may upon 
application be examined by the Board of Registration in Dentistry 
and be licensed by said Board as provided in Section six hereof to per- 
form such service as a dental nurse as shall be specified in his license. 
Except as provided in Section two in this Act, the person desiring 
such registration shall specify in his application the name and address 
of the registered dentist by whom he is to be employed, and this ap- 
plication shall be approved in writing by such registered dentist. No 
registered dentist shall have at one time more than one registered 
dental nurse in his employment. No business firm or private in- 
corporated dental company shall employ more than one registered 
dental nurse at one time, in any office managed or owned by it. Such 
license shall be valid for one year from the date thereof unless revoked 
by said Board for the violation of the conditions thereof. Any license 
isued under the provisions of this Section may be renewed without 
further examination in the discretion of the Board, from year to year, 
upon payment of a fee of five dollars. 

Sec. 2. Any person who is eighteen years of age or over and in 
the opinion of the Board of good moral character may, upon applica- 
tion, be examined by said Board and licensed as aforesaid to serve as 
a dental nurse in any of the public educational or charitable institu- 
tions in the state approved by said Board, which institution shall be 
specified in the license, provided that this application shall be endorsed 
by the authorized officers of such institution. Such license shall be 
limited to the performance of service in connection with institutions 
of the character specified therein and may be renewed from year to 
year without further examination and without the payment of any 
fee therefor. Any number of dental nurses may be licensed for ser- 
vices in connection with any such institution. Any license issued un- 
der the provisions of this Section shall expire forthwith whenever the 
registered dental nurse shall cease to render such services solely for 
institutions of the character specified in the license. 

Sec. 3. A registered dental nurse shall be licensed to perform only 
such duties as shall be specified in his license and solely in the office 
and under the direction of a registered dentist. No dental nurse shall 



270 Practical Oral Prophylaxis. 

be licensed to perform any service other than the examination, wedg- 
ing and cleaning exposed surfaces of teeth, inserting and changing 
dressings in teeth for the relief of pain and assisting a registered den- 
tist during the performance of his dental operations. 

Sec. 4. Any member of said Board or its agent may at any time 
visit any office or institution in which a licensed dental nurse shall be 
employed and make such examination as he shall see fit in order to 
determine whether the provisions of the laws regulating the practice of 
dentistry and dental nursing have been complied with. 

Sec. 5. Any licensed dental nurse changing employers must notify 
the Board forthwith of such change and also of the name and address 
of the dentist by whom he is to be employed. 

Sec. 6. Whenever by the terms of such license the holder thereof 
shall be authorized to perform all of the services specified in Section 
three hereof, and shall have the title of Registered Nurse, such holder 
shall have the right to use the title Registered Dental Nurse. An ap- 
plicant who fails to pass an examination satisfactory to the Board, and 
is therefore refused registration, shall be entitled within one year after 
such refusal to a re-examination at a meeting of the Board, called for 
the examination of applicants without the payment of an additional 
fee. 

Sec. 7. The Board may, after a hearing, by a vote of a majority 
of its members, annul the registration and, without a hearing may 
annul the registration and cancel the license of a dental nurse who 
has been found guilty of a crime or misdemeanor. 

Sec. 8. The Board shall have power to register in like manner, 
without examination, any person who has been registered as a pro- 
fessional dental nurse in another state under laws which in the opinion 
of the Board maintain a standard substantially equivalent to that of 
this Act. 

Sec. 9. The Board shall investigate all complaints of violation of 
the provisions of this Act, and report the same to the proper prose- 
cuting officers. 

Sec. 10. Whoever, not being authorized to practice as a registered 
dental nurse within this Commonwealth, practice or attempts to prac- 
tice as a registered dental nurse, or uses the abbreviation R. D. N., or 
any other words, letters or figures to indicate that the person using the 
same is a registered dental nurse, shall for each offense be punished 
by a fine of not more than one hundred dollars. Whoever becomes 
registered or attempts to become registered, or whoever practices or 
attempts to practice as a registered dental nurse under a false or as- 
sumed name, shall for each offense be punished by a fine of not more 
than one hundred dollars, or by imprisonment for three months, or 
by both such fine and imprisonment. 

Sec. 11. This act shall take effect upon its passage. 



CHAPTER XXII. 

TEACHING OF ORAL HYGIENE, PROPHYLAXIS 
AND PYORRHEA IN DENTAL COLLEGES. 

PRACTICAL METHODS EMPLOYED BY THE AUTHOR. THE 

RESULTS OBTAINED. THE NEED OF SUCH INSTRUCTION. 

The subjects of oral hygiene, prophylaxis and pyorrhea 
are receiving more and more attention each year in our den- 
tal colleges. Having taught these subjects for several years, 
I give some suggestions that may prove of value to those 
just beginning the work. 

If practical, the course should be divided as follows: 
Freshmen receive the course on oral hygiene, the Juniors 
prophylaxis and the Seniors pyorrhea. In order to make 
the lectures of a personal character and to elicit interest, it 
is best to make a personal examination of the mouths of 
each class and tabulate the result. Call attention to any 
defect or treatment needed. The students should be called 
into a private room, one at a time, for the examination. 
Before final examinations another examination should be 
made and credit mark given for any improvement. If the 
lectures have been interesting, these make the work of prac- 
tical value. If this is not done, or where no lectures have 
been given on these subjects, we find many Seniors going 
out with their mouths in a condition which is a disgrace to 
the profession which they will represent. 

At the first lecture take into the hall a new tooth-brush, 
floss silk, quill tooth pick and dentifrice. Ask for a volun- 
teer from the class to come to the rostrum. Give him the 
tooth brush with the request that he brush his teeth exactly 
as he practiced at home. He generally will make a poor 
showing. Then take the brush in your own hands and brush 



272 Practical Oral Prophylaxis. 

the teeth correctly. See that the student can do this cor- 
rectly before he leaves the stand. Then explain to the class 
that if a student of dentistry does not know how to brush 
his teeth, they can expect their patients to know less. The 
use of the silk and other accessories are also shown. The 
demonstration of the proper method of rinsing the mouth 
is sometimes a revelation even to a Senior student. 

In teaching prophylaxis, it is well to divide the class into 
sections of twenty each. Take one section into the dental 
infirmary. Seat one-half of them in dental chairs and have 
the other ten get out their prophylaxis instruments and go to 
work on those seated. Go from chair to chair, showing 
each individually how to hold their instruments. At the 
next clinic the men who did the work before are seated in 
the chairs with each section until every member of the class 
has his mouth put in good condition. Many of their gums 
will be cut with instruments, tissues lacerated and plenty of 
calculus left on their teeth. However, it will be worth all 
the discomfort they endure, for it teaches them the best 
lesson possible. As you proceed with the course induce the 
boys to take monthly prophylaxis treatments among them- 
selves. 

One of the most convincing arguments for a permanent 
interest is for the teacher to exhibit some of his private 
patients who have been on prophylaxis for some time, just 
to show them what can be accomplished. 

In teaching pyorrhhea, the cases which were found in the 
examination of the students' mouths should be used for clin- 
ical material, so that the various treatments can be given 
under their direct observation. If several cases be under 
treatment they should be turned over to the students for 
dressing and applications and the progress closely watched 
by the professor. No set method of dealing with this lesion 
should be given, but demonstrate all procedures which seem 
to have any virtue. 



Teaching Subjects in Dental Colleges. 273 

One session the writer noticed that the students of the 
Senior class were lacking in practical application of his ef- 
forts to have them carry off the spirit as well as the letter of 
his lectures. This following notice was posted on the bul- 
letin : 

"To the Senior Class: 

"Without further notice, an examination of the mouths 
of the Senior Class is soon to be made and the mark given 
at this time will count on the final examination. Any one 
presenting an unclean or diseased mouth will not receive my 
name on his diploma." 

The report soon came to me from the demonstrator in 
the Infirmary that he could not get any work out of the boys, 
because they were so busy cleaning up each other's mouths. 
When the graduating exerises took place, it was my pleasure 
to know that the Senior Class presented the cleanest mouths 
of any class that had ever gone out of the institution, and I 
believed that many of them would be future missionaries 
along this line of work. Later results have shown that this 
supposition was correct, for I have heard of the members 
of the class giving lectures before the schools in the various 
towns and leading in school inspection work. Most coi 
leges now have some lectures on this subject, and a few of 
them have regular chairs, and it is to be hoped that a greater 
number will see the wisdom of giving this subject the im- 
portance which it deserves. 

Of interest, showing the trend of the times towards teach- 
ing this subject in the dental colleges, is the following state- 
ment from Dr. G. V. Black, of the Northwestern Dental 
University School, who, in a letter to me, April 4, 19 13, 
says, "I have been silent on this subject for a number of 
years. In fact, I have not written anything since the article 
for the American System of Dentistry, until quite recently, 
but a couple of years ago I re-arranged the curriculum 
somewhat, and took this subject myself, on purpose to have 



274 Practical Oral Prophylaxis. 

the opportunity of giving my time to it, and of finally writ- 
ing what I might wish to say." 

Dr. N. S. Hoff, of the University of Michigan, in answer 
to my inquiry of his views on this subject, wrote me March 
I, 1 9 13, "The need for this work is tremendous, and I 
sometimes feel as though it is a particular form of work 
which will have to be done independent of the dental col- 
lege work, as I am confident when it is taken into dental 
college work, it will absorb so much of the time that other 
forms of instruction will suffer, just as I have found it to 
do in private practice. It is impractical to do this work in 
connection with the general practice for the reason that it 
absorbs so much time. The dentist becomes so much in- 
terested in it that he is not willing to allow any patient to 
go until he has given him a complete treatment, and when 
this is undertaken, necessarily other lines of work must be 
set aside." 

Dr. C. M. Gearhart, writes me an interesting letter, from 
which I quote as follows: 

"I have been struggling for years teaching 'Oral Hygiene 
and Prophylaxis' in Georgetown University without a text- 
book. Oral Hygiene covers such a multitude of sins that I 
have found it necessary, in a way, to have to review, or 
rather lapse over subjects taught by other men in George- 
town, in order to make the subject worthy of giving it a 
course. It has always seemed to me that the teaching of 
oral hygiene is something more than merely explaining to 
students that they should keep their own, and advise their 
patients to keep their mouths clean." 

The second edition of the book finds an entirely different 
status of conditions in regard to teaching these subjects in 
the dental college. Just two years since the date of the 
above quotations, nearly all colleges have a regular profes- 
sor on Oral Hygiene, Prophylaxis, and Pyorrhea Alveo- 
laris. The condensed lectures as sent the author show a 
great advance in this work. The students are generally en- 



Teaching Subjects in Dental Colleges. 275 

thusiastic and have gladly fulfilled all requirements for such 
a course. If even a small number after graduation carry 
out their teachings in Oral Hygiene and Prophylaxis, many 
of the problems of decay and pyorrhea will undoubtedly be 
solved in the near future. 

Dr. Flora N. Haag of the Ohio College of Dental Sur- 
gery writes : 

"I will send you a list of seven rules which I have out- 
lined for the Junior and Senior students for their cases of 
Prophylaxis. They know each rule must be followed out 
for every case of Prophylaxis and it gives a very clean, 
pretty operation. They are graded in this manner: Ten 
credits are given if every rule has been observed and the 
work is well done. One credit for each rule, the number of 
the rules which is seven, gives them seven credits, leaving 
three credits for the proficiency of the work. Should the 
student forget any one rule, for instance, should he forget 
to attach the small napkin on right hand side of towel, one 
credit is deducted. This napkin is for the purpose of wiping 
deposits or hemorrhage after leaving the mouth before re- 
turning to sterilizing dish. Should the student forget to in- 
struct the patient as to the care of his teeth, a credit is de- 
ducted and so on. I have found this method very satisfac- 
tory. 

"Rule 1. Have all preparations made before beginning 
operation. 

"Rule 2. Place upon bracket the following: 

"(a) Glass dish containing antiseptic agent for recep- 
tion of scalers, files and pyorrhea instruments for use dur- 
ing operation. 

"(&) A dish containing pomice mixed with Phenolso- 
dique or diluted peroxide, glycerine and a drop of Iodine. 

"(c) An orange-wood stick. 

"(d) Port polishing handle and Morgan Moxfield's 
wood point. 

" (e) Rubber cup and brush. 



276 Practical Oral Prophylaxis. 

"Rule 3. Secure napkin (6 inches square) on right hand 
side of towel. 

"Rule 4. Before proceeding with operation spray mouth 
or hand patient half glass of water containing three or four 
crystals of permanganate of potash flavored with two or 
three drops of wintergreen. 

"Rule 5. After polishing, massage gums with some good 
dental cream on tip of forefinger. 

"Rule 6. Before dismissing patient instruct how to brush 
and care for teeth. 

"Rule 7. Use no more time for case of Prophylaxis than 
absolutely necessary." 

It is hoped that this book will, in some degree, meet the 
requirements along this line, and that it may stimulate other 
teachers of this subject to record their experiences and 
methods of teaching. 



PART III. 

A PRACTICAL DESCRIPTION OF PYORRHEA 
ALVEOLARIS AND ITS TREATMENT. 



CHAPTER XXIII. 
PYORRHEA ALVEOLARIS. 

SYNONYMS. NOMENCLATURE. DEFINITION. CAUSES. 

WHAT IS TARTAR AND ITS FORMATION ? KINDS OF DE- 
POSITS FOUND ON THE TEETH. BLACK* S THEORY 

OF TARTAR FORMATION. 

Authorities in general medicine and surgery have in a 
scientific way decided upon a certain framework for the 
description of any disease. Failure to adhere to this frame- 
work by dentists is one of the reasons why we have not 
come upon any common ground in our writing on pyorrhea. 
Having received reprints by the hundred, written by the 
most prominent men in the profession, I find that they vary 
greatly in describing pyorrhea and do not adhere to the 
commonly accepted methods of description. The frame- 
work used for the description of pyorrhea should be: i, 
synonyms; 2, definition; 3, causes; 4, pathological anatomy; 
5, symptoms; 6, diagnosis; 7, prognosis; 8, treatment. 

If we notice the various reprints on pyorrhea, we will 
find that in some of them the prognosis is described first, 
probably the same paper ending with pathological anatomy. 
It would greatly simplify matters if writers and teachers 
of this subject would describe it in a systematic manner. 

SYNONYMS. 

Here we have such a large and unfortunate list that the 
student is completely bewildered in his selection: 

Dr. Rehwinkel first called it pyorrhea alveolaris in 1877, 
in the city of Chicago, although the name was used in 
France as far back as 1870. 



280 Practical Pyorrhea Alveolaris. 

Black called it phagadenic pericementitis in 1882. Riggs' 
disease (Bishop), infectious alveolitis, cemento periostitis, 
calcic inflammation (Black), blennorrhea alveolaris, hem- 
atogenic pericementitis, phagedenic pericementitis (Black), 
chronic alveolitis, interstitial gingivitis (Talbot), perios- 
titis dentales (Schiff), alveolar pyorrhea (Smith), chronic 
alveolar osteomyelitis (Medalia), oral sepsis (Hunter, oi 
London). Edematous peridentitis, hypertrophic periden- 
titis, suppurative peridentitis, gangrenous peridentitis 
(Hoff), alveolar-osteomyelitis. 

Dr. H. M. Fletcher, of Cincinnati, urges the adoption of 
the following classification: 

Initial or simple alveolitis, non-suppurative alveolitis, 
suppurative alveolitis, necrotic alveolitis, acute alveolitis, 
descriptive subdivisions: 

Chronic non-suppurative alveolitis. 

Chronic suppurative alveolitis. 

Necrotic non-suppurative alveolitis (always chronic). 

Necrotic suppurative alveolitis, (nearly always chronic 
but may be acute). 

Zentler, of New York, suggested the name alveolar-den- 
tal-arthritis, classifying it as the primary, secondary and 
tertiary dental arthritis. 

Dr. M. L. Rhein classifies pyorrhea by the addition of 
adjectives stating the name of the disease which he thinks 
causes the symptoms i. e. "Diabetic Pyorrhea" and "Tuber- 
cular Pyorrhea." Prof. W. D. Miller, in his text book on 
pyorrhea, adopted this classification. 

Many dentists prefer the term "Riggs' Disease," because 
the older practitioners believed that the honor for the be- 
ginning of the surgical work should be given to Dr. John 
M. Riggs, of Hartford, Conn., as he was the first man to 
advocate a treatment or even to say that it could be cured. 
The same sort of sentiment prompted this naming as the 
calling of interstitial nephritis "Bright's Disease." In later- 
day nomenclature, the fault of this method of adopting 



Nomenclature. 281 

names has been realized and efforts are being made to 
change many of them. 

Vinchow suggests as a substitute for Pyorrhea Alveolaris 
the term Alveolo-Necrobiosis. 

Mitchell, of Pittsburg, endorses this term for the follow- 
ing reasons, "Necro-biosis, death in life, plus the locational 
indication alveolar, thus Alveolo-Necrobiosis. This term 
distinguishes this disease from all other oral mal-manifesta- 
tions. A dental abscess results from the death (total 
throughout) of the pulp, within the tooth. No other in-the- 
mouth condition save the necrobiotic process, manifests a 
gradual, cell by cell necrosis, to the point of complete ex- 
foliation of structure." 

The author recognizes that reform is needed in our 
nomenclature to describe diseased conditions about the 
teeth. At his request the following essay on "Nomencla- 
ture" was prepared for this work by Andrew J. McDon- 
ough, L.D.S., Professor of Periodontology, The Royal Col- 
lege of Dental Surgeons of Ontario. 

NOMENCLATURE. 

Language is a vehicle used for the transference of 
thoughts. It is necessary therefore that language used in 
scientific pursuits should be fashioned in such a way that no 
mistakes in the meaning are likely to occur. This fact has 
been felt always by scientific investigators and an effort has 
been made and is constantly being made to make our lan- 
guage as descriptive as possible, to make our words desig- 
nating an object or action or condition. Consequently our 
Dental literature which is young, even as is our profession, 
continually makes use of some new word or combination of 
words. 

This is necessary, undoubtedly, because Dentistry being 
young and vigorous is rapidly progressing, rapidly under- 
standing conditions hitherto but vaguely comprehended and 
is finding the necessity of producing descriptive nomenclature 



282 Practical Pyorrhea Alveolaris. 

to cope with the ever present newly discovered situations 
and conditions. Also many conditions, fairly well under- 
stood in certain localities by certain groups of men, have 
been spoken of by each particular group in its own partic- 
ular mode of expression, consequently, when one man or 
group of men, who were using the same nomenclature, de- 
scribed certain pathological conditions, they have not been 
understood by another group of investigators who described 
the same conditions but used different language, the reason 
being, that for certain conditions, there has been no univer- 
sally accepted nomenclature. Better evidence of this asser- 
tion could hardly be given than the great number of terms 
used to describe the pathological condition of the mouth re- 
sulting in the destruction of the tissues surrounding the teeth 
and the eventual loss of the teeth thereby. Without analyz- 
ing the merits of all the different terms used for the descrip- 
tion of this condition, some of which undoubtedly have a 
certain amount of merit, though nearly all, if not all, the de- 
scriptive terms used are descriptive only of some phase ex- 
hibited in this pathological condition. For several years 
now, in my lectures to the students at The Royal College of 
Dental Surgeons, I have tried to use terms based on the 
fundamental fact that there is always a destruction, possibly 
very minute at times, but existing just the same, a destruc- 
tion of some of the tissues surrounding the teeth, therefore 
I have made use of the Greek word KXa^ (Klan) — as a 
foundation for my nomenclature. 

There is no one tissue which immediatetly surrounds all 
parts of a tooth in the same way as we have the periosteum 
surrounding a bone. In other words we have no peridental 
membrane. It is true we have pericemental tissue or dental 
ligament and gum tissue intimately connecting with the bone 
of the alveolus, and we have Naismith's membrane, alto- 
gether making peridental surroundings or tissue. If we can 
get a term which is broad enough to include the disease or 
destruction of any and all of those tissues and then be able 



Nomenclature. 283 

by means of supplementary words or syllables to designate 
the disease or destruction of any one of the component parts 
of this peridental tissue, and also to describe different de- 
grees and different kinds of pathological conditions refer- 
ring thereto, we will have a fairly descriptive nomenclature. 

By using the Greek words 0<Wc (Odous) a tooth, K/jxv 
(Klan) to break, Hepi (Peri) around, and make of them 
a combination, we get the word Periodontoclasia, meaning a 
breaking down of the tissues surrounding a tooth. This 
word though fairly long is not as long as Maxillary Pyor- 
rhoea Alveolaris, to which we have become fairly accus- 
tomed and for want of a better term have perhaps used it 
more frequently than any other to indicate all phases of 
peridental disease. 

If we do not desire to use Periodontoclasia, exclusively 
two much shorter words will convey the same meaning and 
are perhaps more apt to be more universally used, viz. : 
Dental Periclasia. 

Using the words Tlep^ (Peri), OSovg (Odous), and \6yog 
(Logos), we can express the study of this pathological con- 
dition as Periodontology. We can speak of one who de- 
votes his entire time to the study or treatment of it as a 
Periodontist, one who practices Periodontia. We can speak 
of suppurative or non-suppurative periodonto-clasia or den- 
tal periclasia. 

We can have acute or chronic conditions and instead of 
using a pyorrhea instrument in our operations, which 
would mean a pus running instrument we can have a perio- 
dontic or periodontal instrument and so on. 

The use of these terms does not necessarily mean that 
many of the terms which we use, must become obsolete. 
For instance, gingivitis may be a phase in periodontoclasia, 
nevertheless gingivitis conveys a definite meaning to our 
minds and is a good term. It is possible to have a condition 
designated by Maxillary Pyorrhea Alveolaris but it is just 
one condition describing a phase of Periorontoclasia and can 



284 Practical Pyorrhea Alveolaris. 

be expressed under the title suppurative periodontoclasia. 
There is a condition of periodontoclasia which is seldom 
described. Sometimes the bone of the alveolus wholly or 
partially disappears, so that the teeth and the surrounding 
tissues move easily on pressure, yet there is no pus discharge 
at the gingival margin and no break in the peridental tissues. 
This phase of periodontoclasia can be designated by the 
term Alveolar Osteoclasm. Of course, the term, alveolar 
osteoclasia can be applied to a breaking down of the maxil- 
lary alveolar tissue whether accompanied by infection or 
not, so long as we use the proper qualifying term, suppura- 
tive or non-suppurative. 

When infection has taken place and the condition is 
chronic we will have an osteomyelitis which will sometimes 
result in necrosis of the maxillary bone and carry us beyond 
the realm of periodontoclasia, but in this article we are not 
dealing with the nomenclature of pathological conditions 
which are not immediately contiguous to the teeth. 

There is just one other term which will be taken up in this 
article namely, "Tartar." This word is so often used and 
so seldom challenged that one is apt to forget that it is not 
correct and to forget that it had its birth through a misun- 
derstanding of the conditions which it was supposed to des- 
ignate. It is generally conceded at the present time that so- 
called "tartar" is a deposit principally made up of lime salts 
which are thrown down from the saliva, the saliva meaning 
the secretions of all the glands leading into the mouth and 
usually spoken of as mixed saliva. The aforesaid deposit 
therefore is more correctly spoken of as Salivary Calculus. 

If we do not remember this fact we are apt to speak of 
removing tartar from the end of a root which has had a 
chronic alveolar abscess on it and also of removing tartar 
when we mean serumal calculus from other positions on a 
tooth root. 

There are some terms such as Oral Hygiene and Oral 
Prophylaxis about which the profession are at present un- 



Definition. 285 

decided and about which opinions are expressed in another 
part of this book and which will some day have a perfect 
definition accorded to them, but at present the foregoing 
are the only words on which the writer desires to express 
an opinion. 

In writing on the "Bacteriology of Pyorrhea Alveolaris" 
Dr. C. P. Brown says of the name: 

"While this name may not be scientifically descriptive, its 
use during approximately half a century has given it asso- 
ciations which can not be misunderstood." — N. Y. Med. 
Journal. 

The author is not convinced that any one of the above 
should be accepted. However common usage at the present 
time almost compels us to use the term pyorrhea alveolaris 
until a better term is suggested and adopted. 

DEFINITION. 

Dr. Chas. B. Atkinson, defined this condition as u a dis- 
ease following congestion of the myxomatous tissue of the 
oral cavity, affecting with wide range of loss, the gingivae, 
alveoli, and teeth, from slight recession of the gums to en- 
tire solution of alveolus, and the consequent loss of tooth or 
teeth involved; therefore, perhaps more properly 'pyogenic 
gingivitis." 

Dr. C. N. Peirce described it as follows: "A chronic 
inflammation of the pericemental membrane, attended by a 
congested, spongy and tumefied condition of the. gums and 
mucous membrane, and usually accompanied by a persistent 
flow of pus from the alveolar sockets. In the progress of 
the disease the alveolar process, under the influence of en- 
gorgement of the periosteal vessels, becomes involved and 
eventually undergoes atrophy or absorption, leading to an 
exfoliation of practically normal teeth," and ascribes its 
etiology to the uric acid diathesis of the patient. 

Dr. G. V. Black describes it as "a specific infectious in- 
flammation having its beginning in the gingivae, and accom- 



286 Practical Pyorrhea Alveolaris. 

panied with the destruction of the peridental membranes 
and alveolar walls," and while not committing himself, says 
that probably it is caused by the presence of some peculiar 
form of micro-organism and that it is infectious. 

Dr. Rhein defines it as follows: "While pyorrhea alveo- 
laris literally means a discharge of pus from the alveolus, 
the simplest definition of its pathogenic condition commonly 
accepted under the term would be that it represents a dis- 
eased condition of the peridental region due to impaired 
nutrition." 

Dr. D. D. Smith says, "mouth pyorrhea is a disease of 
uncleanliness." 

Dr. W. J. Younger preferred the name pyorrhea alveo- 
laris and gave this definition: "Pyorrhea alveolaris is char- 
acterized by an inflammation of the gums and a deposit of 
characteristic greenish gray or slate colored tartar and the 
wasting of the alveoli accompanied by the formation of pus 
and pus pockets between the tooth and alveolus; the disease 
being due, as I believe, to a specific bacillus. The disease is 
chronic in its duration and results in the ultimate loss of the 
teeth. This slate colored incrustation of which I have 
spoken, I consider pathognomonic of the disease." 

Pickerill in his book on "Oral Sepsis" gives the following 
definition: 

"Pyorrhea alveolaris is essentially a suppurative process 
occuring in the joint around the tooth between it and the 
jaw bone;, it may be localized or general, but usually is 
lound associated with groups of several contiguous teeth. " 

Dr. A. F. James in his president's address of the first 
meeting of the American Academy of Oral Prophylaxis and 
Periodontology (Washington, D. C, November, 19 14) 
gave the following interesting description: 

"I call pyorrhea alveolaris a 'disease,' but I am not able 
to convince myself that the word is a correct one in the sense 
that Rigg's disease has, or ever will be found to have a 
specific organism as its source. To-day, we are justified 



Causes. 287 

more properly in speaking of it as a condition — a condition 
of active fermentation which has advanced to the stage of 
infection and is attacking the tissues through an entrance 
gained at some point of irritation or abrasion of the general 
margin. But because we do not know the specific organism 
of pyorrhea (if there is a specific origin) we need not dis- 
trust any of the facts which have been accumulated during 
the long years of our practice. We need not distrust them 
any more than a physician in the tropics need distrust his 
diagnosis when a patient has been exposed to the attacks of 
stegomyia and exhibits acute symptoms of yellow fever; 
although, the inimical organism of yellow fever has not been 
isolated." 

CAUSES. 

The etiology of pyorrhea is given as local and constitu- 
tional. A few years ago the latter was advocated by many 
of the leading men of the profession and many valuable 
papers were published and read upon "Uric Acid Dia- 
thesis," "Rheumatism," etc., as the etiologic factor, but to- 
day those who are making the greatest success of their 
treatment are almost unanimous in their opinion that local 
causes should be decided upon as the greatest factor. 

It is not denied that the general systemic condition of 
the patient has an influence and must be looked into and 
treated, but this should be considered as only a predisposing 
factor or complication of the pyorrhea. Personally, we 
believe that if a mouth is maintained in a good condition, 
with the absence of local causes hereafter mentioned, no 
systemic disorder would ever produce a case of alveolar 
pyorrhea. In other words, there are no systemic reasons 
for the cause of pyorrhea other than those which may pre- 
dispose to any disease. 

Younger claims that temperament has no bearing on this 
disease, while Smith opposes this view with the declaration 
that pyorrhea never develops in the purely sanguine but al- 
ways in the bilious, the lymphatic, and the nervous temper- 



288 



Practical Pyorrhea Alveolaris. 



ament. Impaired nutrition, heredity, constitutional disor- 
ders, excessive lime salt secretion, uric acid salts, scurvy, lux- 
ury, sedentary habits, toxic agents introduced into the sys- 
tem, chronic infections, and the eruptive fevers have also 
been named as causative agents of pyorrhea alveolaris. 

In answer to those who hold the above causes Hutchin- 
son says : 

"I have no doubt that in cases where diabetes, syphilis or 
other serious systemic disorders are coincident with pyor- 
rhea, the pyorrhea antedates the constitutional disorder and 
has been accentuated but not caused by such disorder. If 
such mouths had always been under prophylactic treatment 






Fig. 78. These pictures illustrate the serious responsibility we assume 
to allow the ordinary bridgework to remain in the mouth. The X-Ray is 
our surest guide in these cases. (A) Too long a span, and too much 
stress on the abutments. Replaced with a removable bridge with 
bracing bar to opposite side of mouth. (B) This bridge should never 
have been put on. The teeth were loose when inserted. The teeth had 
to be extracted. (C) This patient had several teeth under bridges 
with no attachment to jaws. When bridges were removed, these teeth 
came with it. This patient suffered with rheumatism, which got better 
when these bridges were removed. (D) A bridge and teeth still firm 
but about to be shed. (Author's cases.) 



Causes. 



289 



I believe there would be no pyorrhea. The amount of tis- 
sue lost, both hard and soft, indicates that the process of 
destruction has covered a period of many years and could 
not have taken place within a comparatively short time. 
Usually pyorrhea in some stage exists long before it be- 
comes manifested to either the patient or the dentist, and so 
the error of believing it to be of recent occurrence is often 
made." 

The initial cause of pyorrhea is sometimes so small and 
simple as to be overlooked. As before stated, the object 
of this discussion is to be of a practical value and only the 
causes that we positively know and see every day are given: 




Pig. 79. The kind of crowns and bridgework which either cause 
pyorrhea or loss of teeth when placed on teeth. (A) Molar wing bridge; 
notice the fit of abutment. (B) Wing bridge worn by patient for fifteen 
years. (C) Wing bridge which by excessive strain and bad fit of 
crown caused pyorrhea and loss of tooth. (D) The worst fit in collec- 
tion. (E) An ill-fitting gold crown put on with extension to splint 
adjoining loose pyorrhea tooth. E'nlarged. (Author's collection.) 



290 Practical Pyorrhea Alveolaris. 

1st, Deep interlocking cusps on bridge work, causing too 
great an irritation on the abutments and setting up inflam- 
mation in the membrane supporting them, finally giving 
rise to pyorrheal conditions. (Fig. 78.) 

2d, Wing bridges. (Fig. 79.) 

3d, Bad bridge work with special reference to sanitation. 
(Figs. 78-79.) 

4th, Partial dentures which may have any kind of swing 
on one tooth. 

5th, Ligatures, clamps and wedges in ordinary dental 
operations where the contusion of the gum margin is not 
treated after their removal. 

6th, Mal-occlusions of natural cusps, fillings, or crowns. 
Whether mal-occlusion is a cause or result of pyorrhea, 
there can be no doubt about its importance, no matter what 
the treatment may be. One of the greatest aids is in grind- 
ing down markedly prominent cusps and in putting out of 
action those teeth which are weakened by this disease. The 
best method of determining this is to place the index finger 
longitudinally across the teeth and then let the patient close 
the mouth, and shake the teeth. If this discloses the fact 
that the affected tooth is being moved to a greater extent 
than the others, it is an indication that too much stress is 
being placed thereon. 

Dr. R. G. Hutchinson, Jr., of New York, says : "Of late 
I have been more impressed with the importance of mal- 
occlusion, either general or localized, as a prime factor in 
the establishment of pyorrhea, and my first attention is 
given to this correction by grinding." 

Dr. Hartzell does not take kindly to mal-occlusion as a 
cause of Pyorrhea. He believes that the bone destruction 
there is just as any other type of mechanical imperfection, 
in that the conjestion of the tissues, due to over application 
of force, leads to adema and the weakening of tissue resist- 
ance which enables bacteria to gain access more easily. As 
proof of this, he calls our attention to the fact that when an 



Causes. 291 

infection occurs, it begins in the interproximal tissues, or in 
the protected areas where bacteria can grow undisturbed. 

7th, In the disturbance of the contact point of the teeth, 
whether it be from a small separation, or from malshaped 
points, allowing food fibres to pack in and gain a point of 
vantage for future destruction. A large number of pyor- 
rhea pockets are undoubtedly formed in this way, the so- 
called "meat holes." 

8th, One of the most unbearable forms of pain in the 
mouth is caused by the abuse of wood tooth picks and floss 
silk. Splinters of the picks break off in the mouth and, when 
the patient comes for treatment, we sometimes are not able 
to find the cause of the inflammation. This, in time, causes 
loosening of the point of contact, allowing further inroads 
into these inflamed surfaces. 

9th, Any mechanical irritation lodged under the free mar- 
gin of the gums surrounding the tooth will set up initial 
lesions. Shedding bristles from tooth brushes, small seeds, 
grit (possibly left from cleaning the teeth), skin flakes 
from vegetables or fruit — any one may cause this. The 
gum, being unable to free itself from this irritation, inflam- 
mation follows, affecting the peridental attachment and the 
alveolus. 

10th, Pickerill has called attention to the ragged enamel 
at the junction of the crown and root of teeth. Hartzell 
believes this rough surface a culture bed for bacteria, and 
one cause for Pyorrhea. Before beginning his operation, 
he smooths this surface with suitable files, stones, and 
pumice. By giving attention to this surface first, the danger 
of getting pumice into the pocket is not as great as if he 
scaled the root and then used the polishing measures on the 
enamel. 

nth, Tartar formation: While it is true some cases of 
pyorrhea do exist where seemingly there is no deposit of 
tartar present, they are in such minority as to be a rare ex- 
ception. Such cases may at one time have had this forma- 



292 Practical Pyorrhea Alveolaris. 

tion; furthermore, such minute particles can start trouble 
that we can not say with certainty but that all cases have 
some form of tartar which must be removed in our treat- 
ment. The greatest factor in the successful treatment of 
this condition is the finding and complete removal of tartar. 

Many writers do not use the word "tartar," but prefer 
the word "calculus" as more accurate and scientific. Sali- 
vary calculus describes in general that deposit which forms 
on the teeth due to some disturbance (whether physical or 
constitutional) of the saliva. The word tartar is under- 
stood by every dentist and is often used interchangeably in 
the book with salivary calculus. 

1 2th, Uncleanliness: Probably the most important and 
most frequent cause of pyorrhea is that at some period of 
the patient's life there was a lack of intelligent care of the 
mouth. A volume might be written on the causes of pyor- 
rhea, but we have to admit that the greatest factor we have 
to deal with is uncleanliness of the mouth. The first sec- 
tion of this book deals in full with this. 

13, (a) Bacterial invasion and (b) parasites. 

Our scientifically inclined operators and research workers 
are at present giving much thought to these last named 
causes. Great advance is being made each month. We have 
a fairly well-established consensus of opinion in reference 
to the bacterial flora of the mouth, but not so in the case of 
the parasites. 

Only a small amount of data is given on these two causes, 
for the reason that this work is written for the purpose of 
dealing with the practical treatment of the general practi- 
tioner at his chair. The reason lies in the fact that the 
above twelve causes have to receive adjustment and treat- 
ment, no matter what other contributory cause may be as- 
sociated. Another reason is that, if the treatment is prac- 
tical and thorough, good results are sure to follow, even 
though the dentist does not know the difference between bac- 
teria and parasites. The author does not wish to be mis- 



Causes. 293 

understood, for he believes that all dentists should acquaint 
themselves with the general facts conceiving the bacterial 
flora of the mouth, and of the parasites as well. This is 
imperative if the operator contemplates making the treat- 
ment of Pyorrhea a specialty, however, he would not deter 
* the dentist from handling Pyorrhea cases because this 
knowledge has not been acquired. 

(a) The Bacteriology of Pyorrhea. 

The bacteria of the mouth in a Pyorrheal condition are 
so numerous as to kinds and variety that the bacteriologists 
have been unable to agree or to harmonize these difficult 
and complex findings. Almost all discovered bacteria may 
be found in some of these mouths if we examine the mouth 
flora of a large number of cases. The more chronic the 
Pyorrheal condition the greater number, for the simple rea- 
son that they find more favorable conditions to multiply. 

The findings and different views about the bacteria of 
the mouth requires a book in itself and only a few of the 
latest and most authoritative suggestions are mentioned. 

The mouth normally contains the streptococcus. This 
usually is harmless but the most serious consequences some- 
times result from their action. This harmless germ may 
cause septicemia, endocarditis, or the most virulent type of 
Pyorrhea. The modus operandi of this change in charac- 
ter was not well understood until the findings of Dr. E. C. 
Rosenow, who showed that these useful and harmless strep- 
tococcui under certain conditions are transmuted into other 
forms of the pathogenic type. 

Some investigators do not agree with Dr. Rosenow in 
the variety, but think the number is responsible for the se- 
verity of Pyorrheal conditions. Certain it is, the less cared- 
for mouths will furnish a better cultivated and more fertile 
field of bacteria. 

This latter view is held by Prof. Rosenberger of Jef- 
ferson Medical College, Philadelphia. Dr. F. E. Stewart 
thinks the initial lesion of Pyorrhea so lowers the resistance 



294 Practical Pyorrhea Alveolaris. 

of the mouth tissues that bacteria can infect and having be- 
come accustomed to live on living tissue become parasites 
and cause the more serious cases of infection. Prof. 
Rosenberger is also opposed to this view believing that the 
ingress of the bacteria into the blood stream from diseased 
gums does not generally occur, but rather the blood absorbs 
the toxic products of the bacteria. Constant swallowing of 
the products of putrefaction is the cause of whatever gas- 
tric disturbances we may have from Pyorrhea. 

The micro-organisms in Pyorrhea are well protected, due 
to the dense membrane which they inhabit, to the large 
amount of granulating tissue present, calculi, and the fur- 
ther fact that the parts here are so poorly supplied with 
blood vessels. The blood contains special ferments which 
are destructive to bacteria, but, because of the above men- 
tioned protection, they can't be placed into the pocket or 
fort held by the Bacteria. If this were not the case, we 
would probably not have any Pyorrhea infection, for it is 
rare where a case of primary blood infection occurs. For 
this reason, we must see that the. only logical treatment of 
this disease must be to either extract the tooth, or to surgi- 
cally remove this culture bed of infection. 

Nearly all mouths contain the Pneumoccus, whether this 
is the true Pneumoccus is a debatable question. We do 
know that some of the worst infections and complications 
from Pyorrhea are due to its presence. Post operative 
Pneumonia is due in many cases to Pyorrhea mouths hav- 
ing a super-quantity of these micro-organisms. 

The Treponema mucosum is a new species of Spirochaeta 
reported by Dr. Noguochi. This organism presents an ap- 
pearance much like that of syphilis. Its action is Pyoro- 
genic and it will not grow in healthy tissue. The peculiar 
odor of Pyorrhea is produced by this organism. 

Dr. E. C. Rosenow has opened up a new field for those 
who are interested in the bacteriology of the mouth. His 



Causes. 295 

discovery was the transmutation by animal passage of the 
streptococcus vindans into pneumoccus. He explains that 
the organism in rheumatism locate in joints and endocar- 
dium because of the low degree of oxygen pressure in that 
these structures are very avascular in that here we meet the 
end of the capillary supply. The same infection by the 
process of convertion may show streptococcus vindans in 
endocarditis and hemolytic streptoccus in the joints. How- 
ever, the point in his investigation of most importance to 
the dentist is his statement as to the extent of infection and 
the place where these infections occur. "It is safe to say 
that the focus is most commonly found in the oral cavity 
and here in order in frequency is probably the tonsil, pyor- 
rhea and blind abscesses about the teeth." — (Journal Lan- 
cet). 

(b) Parasites in the mouth and their relation to Pyor- 
rhea. 

At the June, 19 14, meeting of the Pennsylvania State 
Dental Society, Dr. M. T. Barrett read a preliminary re- 
port as to finding the parasite entamoeba, buccalis in the 
mouths of forty-six individuals having Pyorrhea Alveolaris. 
This report and the one following it, read at the National 
Dental Society Meeting, at Buffalo, were very guarded as to 
a positive declaration that this organism was the real cause 
of Pyorrhea. 

Dr. C. C. Bass, about the same time, reported the finding 
of amebae in one hundred patients examined. He was very 
positive that this organism was the causative factor. At 
the present time, Dr. Bass is certain that only Pyorrhea 
mouths possess amebae, but offsets this with the further 
statement that about 90 per cent, of our population have 
Pyorrhea. Among the methods given of acquiring this or- 
ganism are: kissing, the common drinking cups, putting ar- 
ticles into the mouth which other people have had in their 
mouths, and contaminated water and food. 



296 Practical Pyorrhea Alveolaris. 

Dr. Bass says that these organisms are in greater num- 
bers in the bottoms of the pockets and that, in this way, the 
bacteria are drawn into the depths of the pockets. 

Since scientific investigations have been in vogue with 
the dental profession, since we have known anything about 
bacteriology, every once in a while some investigator claims 
that certain germs or parasites are responsible for diseased 
conditions of the mouth. However, none of these have had 
the success of the recent investigators, Barrett, Smith, Bass 
and Johns. Like a bolt from a clear sky, before the dental 
profession could make investigations properly, the laity pa- 
pers throughout the land, and the Medical Journals pro- 
claimed that at last the absolute cause of Pyorrhea had been 
found and its sure cure was at hand. Inside of three months, 
the pharmaceutical houses all over our land got out nicely 
printed literature containing the reports of these gentlemen 
on the Endameba Buccalis, claiming that they had the par- 
ticular form of ipecac which was to be our salvation in its 
cure. As soon as some of us could catch up with this rapid 
development, and had begun to catch our breath for investi- 
gation, we found that every dentist in the land was spending 
a larger amount of money for Emetine than they had ever 
spent to cure Pyorrhea before. 

I would not for a moment decry any new movement or 
discovery, and no one is working harder on experiments 
and practical cases to keep up with every new development 
than myself, but I do deem it unfortunate indeed that this 
new development was thrust upon the profession just at the 
time when we had begun to work and master the surgical 
technique necessary to save these teeth, and now comes, 
these gentlemen, deriding such means as having failed. 
Surely it is to be hoped that this attempt to throw aside our 
successful technique will be short lived. 

Of course, in a report of this kind, this matter must be 
brought down to its latest form. First, we must remember 



Causes. 297 

that the bacteria of the mouth are flora, of vegetable origin, 
like wheat or corn. These are microscopical in form. Many 
years ago, investigators found in the secretions of very dirty 
mouths, unicellular bodies, larger bodies, which were not of 
the flora form, but parasitic, these were given the name of 
Endameba Buccalis. The gentlemen above referred to 
about the same time in Philadelphia and New Orleans, found 
more of these in Pyorrhea mouths than in normal mouths, 
this lead them to the conclusion that this was the cause of 
Pyorrhea. These Amebae can be seen moving about in the 
microscopic field, also a large amount of bacteria, then it is 
a question what the amoeba are there for, whether they in- 
tend to, destroy the alveolus or gum structure, or have only 
crawled into these pockets for a meal of bacteria, for this 
reason it is a question whether or not the amoeba is patho- 
genic to human tissue. It is my opinion that the parasites 
are normal residents in even the mouths of children, and the 
greater the bacterial coat, the greater the filth in the mouth, 
the easier they can propagate. In their enthusiasm due to 
their findings, the investigators fail to produce sufficient 
proof of the amoeba as a causative factor. For instance, I 
might say that blue eyes cause Pyorrhea. I might be of 
sufficient importance to have it heralded all over the coun- 
try, saying that fifty per cent, of the people affected with 
Pyorrhea have blue eyes, therefore, blue eyes are the cause, 
and, further, prove the statement by saying that many people 
who do not have blue eyes do not have Pyorrhea. So it is 
with the Endameba Buccalis, they are found in Pyorrhea 
mouths, therefore they cause this disease. I might be pass- 
ing through the fields and find a carcass, the flesh of which 
was full of animal parasites. I would go on a little further 
and find another carcass and in the flesh of this one also 
might be present more of the same parasites, also I could 
remember that years ago I had seen the same thing, then I 
might immediately draw the conclusion that these parasites 



298 Practical Pyorrhea Alveolaris. 

were the cause of the death of the animals, never going back 
to investigate if some other agent had caused the break in 
the continuity of the life of the animals. If we could keep 
the Pyorrhea mouth free from germs, we would probably 
not find the amoeba present in as large quantities. 

It seems to be necessary to recall to the minds of our 
medical friends that the dental profession has for years 
been curing Pyorrhea and that this has been accomplished 
by performing the proper surgical work and after proper 
similation of the structures and only after these procedures, 
have we cured Pyorrhea and then, without regard to 
Amebae. The method used was to remove this coat of 
bacteria and then the tissues given proper stimulation, the 
patient has been cured of Pyorrhea. 

Can anyone look at the dead peridental membrane on an 
extracted Pyorrhea tooth, can anyone look at the skull 
of a dead person who had Pyorrhea and see the bone 
destruction there, can anyone after seeing these sights, say 
that he believes the application of any drug could remove 
the cause of Pyorrhea and cure it? Thus we do not under- 
estimate the importance of Amebae in Pyorrhea cases, but 
we must discredit the reports of the marvelous cures from 
the use of Ipecac only. 

Does it have any bearing on the facts in the case to say 
that a man having Amebic Colitis was given one hundred 
sixty grains of Ipecac without any sign of improvement of 
the diseased mouth? Does it have any bearing on the case 
to say that within one month after this, when his mouth had 
been cleaned up, the disease was eradicated? 

Does it have any bearing on the case to state that when 
I have a splinter in my finger it suppurates, then I might by 
the injection of Emetine arrest the suppuration for a few 
hours, if I should still leave the splinter in the finger, a 
relapse would occur? This is the same relapse that is so 
often spoken of by the investigators who treat Pyorrhea by 



Causes. 299 

Emetine. The cause is still there in both cases and must 
be removed before a permanent cure can be effected. 

I have used Emetine, am using it, and shall continue to 
use it, but it is on thorough surgical work that I depend for 
my cures. In reading the various advertisements of the 
pharmaceutical houses not only of Emetine, but for other 
drugs also, I have been struck with the emphasis which has 
been put on the statement that they are absolute cures with 
slight reference to surgical help. It reminds me of once 
when I looked through an automobile magazine at the vari- 
ous advertisements in regard to appliances for saving gaso- 
line, every one claimed from forty to fifty per cent saving. 
I figured up that by using every one advertised I would 
run my car without water, oil or gasoline. However, I 
still find it necessary to have plenty of all of these before 
starting out on a pleasure ride. Thus it is just as necessary 
for us to go back to thorough instrumentation as it is to 
have oil, gasoline and water to run an automobile, that is 
until some other agent now unknown, is discovered for the 
treatment. 

Read the recent papers by Dr. Bass and compare his 
claims and findings with a paper read before the New York 
Pathological Society, 1907, by Dr. L. T. LeWald, in which 
he showed amebae could be demonstrated in the mouth 
almost constantly, no matter how much care was taken of 
the teeth. The Bureau of Laboratories of the New York 
Health Department will next month publish their report 
on "Amoebas in the Mouths of School Children." If Dr. 
Bass' claims are true, then all school children have Pyorrhea. 

Does it have any effect on the status of Ipecac Treatment 
when we read that Drs. Merritt, Hartzell, Talbot, West, 
McCall and other distinguished investigators in the field 
of Pyorrhea could not verify the results claimed for this 
treatment? A distinguished medical investigator, Rosen- 
berger, of Jefferson Medical College, chair of bacteriology, 



300 Practical Pyorrhea Alveolaris. 

writes me as follows: "The ameba buccalis plays very little, 
if any part in the etiology of Pyorrhea. * * * My own 
results with Emetine have been very poor." Dr. E. C. 
Rosenow, of Chicago, writes me under recent date that 
"the work of Bass and Barrett in the use of Emetine 
in the treatment of Pyorrhea is very interesting, but I fear 
that they have not sufficiently emphasized the need of proper 
dentistry in the way of removal of tartar, deposits, etc., for 
the permanent relief." 

The greatest mistake made by Dr. Bass is that he declares 
every individual has Pyorrhea, just because he believes the 
Ameba is the cause of Pyorrhea, and he finds that in all 
mouths. Dirty, filthy mouths have the largest number of 
these parasites, and it is a strange fact that just such a 
mouth may be free from Pyorrhea. On the other hand, 
Pyorrhea may be present in a well kept mouth. As Pyorrhea 
Alveolaris is an affection of the peridental membrane of 
the tooth with the formation of tartar and the molecular 
death of the alveolar process as its last stage. The most 
severe cases may not have any pus present. 

Many physicians have of late been giving their patients 
Emetine by the hypodermic method without a proper diag- 
nosis of Pyorrhea. Some of their patients have come into 
my office with both arms so sore they could not do their 
ordinary duties. Some of these had no Pyorrhea. I have 
seen ulceration of the mucus membrane of the mouth due 
to the physician prescribing Ipecac as a mouth wash. The 
writer urges physicians to examine and diagnose Pyorrhea, 
but believes the co-operation of a dentist in the treatment 
will result in more good for the patient. 

[Under the sub-head "Treatment by Emetine" will be 
found further information on the subject of the Endameba 
Buccalis.] 



Kinds of Deposits on Teeth. 301 

WHAT IS TARTAR AND HOW DOES IT FORM? 

Tartar is a concreting material, either secreted or con- 
creted in the mouth from the saliva, which is deposited on 
the teeth or artificial dentures. Various hypotheses have 
been advanced in explanation of these deposits. We do 
know that the bulk is composed of calcium phosphate and 
carbonate, and that certain places are more liable than others 
to the accumulations. One theory is that the saliva holds 
these salts in a very unstable suspension, and, in the presence 
of air, carbonic acid gas is liberated and the calcium salt 
precipitated. 

Burchard claimed that the saliva, as manufactured by the 
glands, is of alkaline reaction, holding in solution the salts 
of calcium. His theory was that in most mouths the re- 
action is acid and the coming together of these two opposite 
chemical compositions results in a precipitation which is in- 
soluble in the acid medium. 

A third theory is one of crystallization. Younger holds 
the view that some bacteria form a nucleus or nidus about 
which layer after layer of these salts are precipitated; espe- 
cially does he believe this to be the cause of the formation 
of serumal calculus, the idea being that it was just the same 
as the crystallization of syrup starting around a thread. 
These theories seem to have resulted from the observation 
that calculus formation in other parts of the body generally 
contains a lump of bacteria around which they have been 
formed. 

The fourth hypothesis is that the calcium salts are held 
in suspension, and when the saliva stagnates, the heavier 
substances collect in favored situations. 

KINDS OF DEPOSITS FOUND ON THE TEETH. 

There are probably many variations in the character of 
the deposits on teeth, but the most important from a pyor- 
rhea standpoint are as follows: 



302 



Practical Pyorrhea Alveolaris. 



(a), Sordes is the soft, creamy, pearl gray deposit on the 
teeth and differs from tartar in that it does not concrete, 
though it is sometimes mixed with a form of tartar and par- 
tially concreted. 

(b), Granular mass, less hard than calcium sulphate. 
This is generally found in large quantities on the lingual 
sides of inferior incisors and on the buccal surfaces of the 
upper molars. (Fig. 80.) 




Fig. 80. Deposits of Salivary Calculus. (Author's Collection.) 

(c), Concretions found below the gum margin; color, 
light yellow to dark green. The light concretion is soft 
while the dark one is hard. Some have thought that the 
greenish scales around the margin of the gums might be 
caused by the disturbance of the gingival glands. Patter- 
sons says, "These deposits are from purulent matter and are 
the sequence of irritation and inflammation from the vari- 
ous local causes referred to. They are not precedent to a 



Kinds of Deposits on Teeth. 



303 



lesion but invariably are subsequent to irritation and exuda- 
tion." 

(d), Serumal calculus. (Fig. 81.) 

The red or greenish color of the second variety named is 
given by the escape of heamatin of red blood corpuscles due 
to the rupture of small blood vessels by mechanical irritation 
of the deposit. The extreme hardness and brittleness which 
we often find is probably due to the absorption of uric acid 
from the blood. It is supposed that this occurs only with 
those patients whose system contains a large amount of uric 
acid. From this observation many dentists at one time be- 
lieved that the whole cause of pyorrhea could be explained 
by the theory of the uric acid diathesis; but this theory of 
its etiology has been discarded by the majority of the dental 
and medical profession. 




Fig. 81. Serumal Calculus on Different Places on the Roots of 

Teeth. Absorption or Erosion on C, D and E. 

(Author's Collection.) 



304 Practical Pyorrhea Alveolaris. 

Dr. P. R. Howe reports from his experimentation that the 
only difference between salivary and seruminal tartar is that 
of the ''matrix of deposit." In neither has he found the 
presence of urates. 

The fourth variety of calculus (d) was first called "ser- 
umal" by Brown, of Georgia. This secreting and concret- 
ing material is supposed to be formed from some break in 
the peridental membrane and effusion of the serum of the 
blood. If this theory is correct the process has never been 
successfully explained. 

At the point of location of the other varieties of tartar 
we have direct contact with the saliva, but with the serumal 
calculus it is claimed that the formation may take place in 
the peridental membrane without any show of external com- 
munication with the saliva of the mouth. The very exist- 
ence of such a formation has been denied by many, who 
claim that when calculus is found on a tooth there is always 
some external opening which can be found by careful prob- 
ing with a small instrument under the cervical edge of the 
gum. Nash advanced some strong arguments on the im- 
possibility of the formation of serumal calculus or tophus 
in the peridental membrane. 

BLACK'S THEORY OF TARTAR FORMATION. 

Dr. G. V. Black has recently reported some interesting 
experiments about the formation of tartar. His theory is 
that the susceptible mouth contains a material which he 
terms the "aglutinating substance." This substance is 
transparent and slightly sticky. This serves to gather and 
hold particles of calcium salts which are precipitated from 
the saliva. This gradually hardens after a few days. In 
his personal experiment with a slot cut in his artificial set 
of teeth he advances the idea that salivary calculus may be 
controlled to a certain extent by the diet. Eating too much 
caused him to have a greater deposit, while the use of a 



Black's Theory. 305 

saline cathartic would cause a cessation of deposits for a 
week or more. 

Before the advent of prophylaxis, dentists were paying 
most of their respects to the hard deposits as the principal 
factor in dental lesions but recently we believe this to be a 
mistaken idea, and that the soft deposits are more vicious 
in their action on the soft tissues. In fact, upon the removal 
of large quantities of tartar from the teeth, we frequently 
find the tooth in a well preserved state, and the gums com- 
paratively healthy, but we never find this to be the case 
when the sordes or soft deposits are removed, because the 
latter contain a great amount of infection; we sometimes find 
the tooth in a leathery condition and the soft tissues always 
in a state of inflammation. 



CHAPTER XXIV. 
PATHOLOGY OF PYORRHEA ALVEOLARIS. 

RECESSION AND CONGESTION OF THE GUMS. THE PERI- 
DENTAL MEMBRANE. THE ALVEOLAR PROCESS. 

TOOTH ROOT ABSORPTION. FORMATION OF PUS 

POCKETS. ALVEOLAR ABSCESS IN PYORRHEA. 

RECESSION AND CONGESTION OF THE GUMS. 

The pathology of dentistry should be considered in the 
same manner as the pathology of surgical diseases. In den- 
tistry the attempt to bring up a different pathology has been 
due to a lack of proper knowledge and observation. 

In taking up the work of pyorrhea, the dentist must have 
an accurate knowledge of normal conditions in order to be 
able to detect a deviation therefrom. Also, a complete 
knowledge of the histology of the gums, teeth, and maxilla 
is imperative. First should be noted the appearance and 
color of the normal gum. We will note that there is no 
tumefaction of the gum margin; also that the gum margin 
clings to the teeth at the enamel margin, completely sur- 
rounding the tooth at the insertion into the bone. 

The teeth most often affected by pyorrhea seem to be the 
lower incisors. Next in the order of frequency, the supe- 
rior molars and bicuspids; then the inferior molars and bi- 
cuspids; the superior incisors; lastly, the upper cuspids. 

Recession of the gums is not necessarily a feature of 
the pathology of pyorrhea, although some medical men and 
many of the laity have at times mistaken the recession of 
the gums, especially on the upper cuspids, for pyorrhea. 
This recession is the result of not receiving circulation enough 
to keep up peridental life and a constant diminution of the 



Recession and Congestion of Gums. 307 

thickness of the alveolus and the hardness of the cementum. 
This structure either moulds into the dentine or recedes to- 
wards the root when conditions are abnormal. 




Fig. 82. Recession of gum due to pyorrhea. This is generally greatest 
on lower incisors. This mouth had a large amount of pus present on 
lower jaw, while upper was in fair condition. Patient had been in 
bed about a month with little attention given her teeth. This is a 
curable case. 



The recession of the gums at the cervical margin brings 
most patients to the dentist for the treatment of pyorrhea. 
At this stage we find the peridental membrane either ex- 
posed or destroyed in part, forming a hot bed for the culture 
of bacteria which continue their action in destroying the 
alveolus and inflaming the periosteum. This recession is 
caused by the falling in, as it were, of the supporting struc- 
tures. (Fig. 82.) 

A specialist on the treatment of pyorrhea was once criti- 
cised by a fellow dentist in this fashion, "Dr. doesn't 

treat pyorrhea ; he treats gingivitis, and makes people think 



308 Practical Pyorrhea Alveolaris. 

he is curing pyorrhea." This statement showed the evident 
ignorance of the speaker upon prognosis in pyorrhea. 

The best, and only proper time to begin treatment is dur- 
ing the existence of what he called "Gingivitis." When we 
can get a case in hand when the gum is red and the tissues 
slightly swollen, we are absolutely sure that we can cure the 
case. Woe to the dentist who sees this condition and lets 
the patient run along from bad to worse ! He may soon 
have a case that is not only beyond his control, but is beyond 
the control of the specialist also. So we must say that the 
operator who is curing Gingivitis is doing the best Pyorrhea 
work. 

Although the patient worries about the gums, it is often- 
times the least affected structure and, if the infection be re- 
moved, soon resumes its normal appearance and function as 
a protection to the structures which underlie it. Just as 
often do we find the opposite picture. Instead of recession 
we find a swelling and congestion. On squeezing the gums, 
pus will generally exude. On the other hand, I have seen 
cases where there seems to be no pus; but there is infection, 
and pus either has been or will be the next step in the prog- 
ress of the disease. 

Probably one of the most constant diagnostic points in 
pyorrhea is the tumefaction of the gum tissues. The ex- 
tent of this tumefaction may be from a few lines in width 
at the gum margin to a heavy roll of tissue extending the 
full breadth of the roots of the teeth. This tumefactory 
condition may be hard and firm, and when this is the case, 
the color of the tissue will be a light lilac or, if the pocket 
beneath be extensive, of purplish tint. However, this tissue 
may present a very different clinical picture in that the tissue 
may be very soft and fluffy, bleeding upon slight irritation, 
as in brushing the teeth. In the latter condition we find 



Recession and Congestion of Gums. 



309 



more pus and we also find that the teeth are looser than in 
the former condition described. (Figs. 83-84-90-1 13-1 15.) 




Fig. 83. A typical picture of pyorrhea alveorlaris. Note the founded 
glossy gum tissue. The accumulation of tartar just under the gum. The 
beginning recession. The pus pockets. The flow of pus which has 
flowed out on lower gum and lip due to pressure of holding lip for pic- 
ture. This is a curable case. 



Often the gum is filled with inflammatory exudation, giv- 
ing a rich crimson (chronic state bluish) color, due to the 
accumulation of cells in the connective tissue. (Fig. 82.) 

This gum bleeds at the slightest touch. Inflammation 
may extend only to periosteum or into the alveolus. If the 
condition of swelling continues and the gum continues flabby 
about the tooth, like hypertrophied tissue, the best treatment 
is the surgical trimming with knife or scissors. 

When the patients are about to be dismissed after treat- 
ment, they often call attention to the fact that their gums 
have receded more than they did previous to treatment. 
This seems to them a most serious question, and the dentist 
should be very careful to convince the patients that such re- 



3io 



Practical Pyorrhea Alveolaris. 




Fig. 84. Tumefaction of gum tissue. In young patients this condition 
is more prominent than the so-called pockets. 



cession always follows a correct treatment, because of a re- 
duction of the inflammation and a return of the gum to its 
natural thickness. In addition to this, the alveolus sur- 
rounding the teeth is now much less than before disease, or, 
having been removed in the surgical work, gives the gum 
covering it the opportunity to fall further away from the 
crown of the tooth. 

This recession, if extensive, may, in the future, cause 
trouble for the reason that the flap of gum tissue which 
normally protected the interproximal space from food im- 
pactions may be too low to protect this space against further 
inflammation and infection from packing. It must be well 
understood that in these cases the patient should present at 



The Peridental Membrane. 311 

frequent intervals and have such spaces cleaned by their 
dentist. 

THE PERIDENTAL MEMBRANE. 

The object of the peridental membrane is to transmit 
nourishment to the teeth and to furnish elasticity and a 
cushion under force, or a sling in which the teeth are held. 

Dentists have been taught that the peridental membrane 
partook more of the character of a periosteum, but later 
investigators claim this structure to be a true alveolar-dental 
ligament. Microscopical examination reveals solid bundles 
of fibres of Sharpey which extend from the tooth out into 
the alveolar process. The insertion is about the same as 
ligamentous insertion into bone in other parts of the body. 
These fibres of Sharpey, according to several authorities, 
form circular rings which suspend the tooth in its socket. 

The peridental membrane has for one of its purposes the 
nutrition of the cementum. This membrane may be sep- 
arated from the tooth or completely absorbed at the time of 
the first injury, be it tartar, bad dentistry or infection. 

Healthy strong teeth are often exfoliated from the alveo- 
lus because of hypernutrition, which results in deposits in 
the substance of this membrane making it resemble the ce- 
mentum, or the membrane may be so feeble in its function 
as to shut off nutrition with like result. Cases of loose teeth 
from this cause have frequently been diagnosed pyorrhea. 

At birth the mucous membrane in the mouth affords the 
same protection as in the other parts of the body. As each 
tooth is erupted, a hole is punctured through this protective 
covering, in all, thirty-two holes. Although the tooth fills 
this opening, the margin is always open, as long as a tooth is 
standing in the jaw. In other words, the mucus membrane 
is not attached to the tooth, and leaves, as it were, a crack 
into which the flora and parasites of the mouth are free to 



312 Practical Pyorrhea Alveolaris. 

enter. Where the mouth is in a healthy condition, this crev- 
ice is very slight, but the dirtier the mouth, the wider it be- 
comes, with an increasing load of infection. Thus it is easy 
to see why extraction of a Pyorrhea tooth seems so quickly 
to cure. The irritant being removed, further protection 
takes place on account of the mucus membrane closing over 
the opening where the tooth stood. 

We must bear in mind that an edentulous jaw never pre- 
sents a pyorrheal condition, and that the extraction of the 
affected tooth or teeth affords relief for that part of the 
bone. This is even so when the process has become carious 
in the advanced stages. This leads us to believe that the 
pathological condition is centered around the tooth root and 
its attachment to the bone. 

THE ALVEOLAR PROCESS. 

Tolbot in his well-defined theory would have us believe 
that the alveolar process is of a different structure from the 
rest of the maxilla, and that it is a transitory structure whose 
only purpose is to mould itself about the teeth, and, when 
they are lost, to be absorbed. His experiments and argu- 
ments have been largely accepted by the dental profession. 
The author is of the opinion that the alveolar process is in 
no way different in its characteristics and structure from the 
rest of the bone, and that the socket is simply a medullary 
space, situated in an extension of the maxilla. 

If the initial infection is not removed, the part follows 
the usual course of infection and inflammation. As this 
condition progresses, the tartar and infection continues to 
collect on the teeth and gums until it results in alveolar pyor- 
rhea and we have pus pockets. Now in the event this infec- 
tion is not removed, the bone begins to liquify, constituting 
alveolar caries, and finally the teeth lose their attachment 
and become exfoliated. (Fig. 85.) 



The Alveolar Process. 



3i3 




Fig. 85. This picture was made from a skull carefully selected from 
some two hundred skulls. This specimen exhibits many of the various 
factors in pyorrhea. The cut fails to show the value of the skull. Sali- 
vary and seruminal calculus, all degrees of alveolar destruction and 
eroted roots are present. (From author's collection.) 



In the true sense of the word necrosis, from a medical 
standpoint, can not properly be applied to the molecular dis- 
integration of the alveolus in pyorrhea. Certainly, we do 
not have any considerable bone dying in masses, thus the 
process is more of the character of carious bone. However, 
necrosis is in common usage among dentists in describing this 
condition. 

Dr. F. C. Pague reports to the author a most interesting 
case bearing on the restoration of the alveolar process. This 
case is worthy of close study. 

"I am presenting for your consideration the history of 
a case with X-ray photographs (Fig. 86) of same that will 



314 



Practical Pyorrhea Alveolaris. 



prove to the doubting Thomases of the profession a fact 
that I have had convincing proof of for years, namely, that 
nature will and does build in and around the roots of the 
teeth new constructive tissue, where the bony process has 
been lost through or by the deposits of seruminal calculus on 
the roots of the teeth, providing said deposits are all care- 
fully and fully removed and the surfaces of these roots are 
smooth and polished, and that such teeth thus treated will 
become firm and strong in their sockets, and be immune to 
a return of such conditions if patients will but do their part 
in keeping the surface of their teeth clean and polished and 
faithfully attend to the subsequent treatment in way of pe- 
riodical prophylaxis at intervals of two or three months." 




Fig. 86. After proper measures the alveolar process rebuilt between 
these teeth. (Pague.) 



The Alveolar Process. 315 

u The case is that of a young woman thirty-two or thirty- 
three years of age who lost both bicuspids and first molar on 
the lower left side and had after a time a bar bridge placed 
to take their place, the bridge extending from the second 
molar with a gold crown for posterior anchorage to the cus- 
pid for anterior anchorage, the pulp being removed from the 
cuspid and the anchorage made by placing a gold backing 
lingually supported by a platinum pin extending well into the 
root canal, but because of imperfect occlusion the strain be- 
came too much for the cuspid and after a few years a pyor- 
rhea condition developed that necessitated the removal of 
the bridge. Treatment for pyorrhea followed. When the 
case was presented to me for treatment I found the process 
between the cuspid and lateral all destroyed, extending to 
the apex of the cuspid mesially, while the lateral appeared 
suspended in a pocket of pus, for a pocket extended to the 
apex of the lateral on the mesial surface as well as distally, 
with concretions of deposit on the roots of both teeth so 
dense it appeared almost impossible to remove it, and get 
the surfaces smooth and polished. The X-ray photograph 
(Xo. 1) taken immediately following treatment (April 
27th, 1914) shows clearly the loss of process between the 
cuspid and lateral and central incisor, and also how the lat- 
eral is without apparent support for the deposits were 
found on its apex. After the root was cleaned the rough 
edges of the process were curetted, leaving the tooth in 
rather a critical condition. Under ordinary circumstances 
these teeth would have been splintered immediately by a very 
light linen thread No. 100, but the patient was to pass into 
the hands of an orthodontist to correct a general imperfect 
occlusion, and so I thought best to leave the teeth without 
any support, the patient assuring me she would use the oppo- 
site side of her jaw for mastication, and endeavor not to 
touch or move the teeth. X-ray No. 2 was taken about four 



316 Practical Pyorrhea Alveolaris. 

months after No. i (August 15th, 1914) and in that can 
plainly be seen nature's effort at reconstruction. How she 
is filling in new tissue between the central and lateral in- 
cisors and how she is struggling to fill in between the lat- 
eral and cuspid, but you will observe the reconstruction is 
higher and more dense towards the lateral than the cuspid, 
and a small spicula of bone is reaching out along or close to 
the lateral with a sloping off with a lighter shade towards 
the cuspid, and this illustrates the difference between a vital 
tooth and one that is not. The heavy dark outline in the 
cuspid represents the gold backing on the lingual surface and 
platinum pin, with a lighter shading in the canal beyond the 
pin which is the gutta purcha point or filling. Nature is far 
more rapid in its upbuilding of new tissue about the root that 
is vital than one that is not, but while some writers contend 
that nature will not rebuild lost tissue about a devitalized 
tooth, I can hereby prove as clearly as one can discern white 
from black, that she does build in the same way (only more 
slowly) reconstructive tissue and that a devitalized tooth will 
become as firmly set as one that is vital. For proof of this 
assertion examine X-ray No. 3, taken December 7th, 19 14, 
a little less than four months later than No. 2. No. 4 was 
taken March 29th, 191 5, and shows the regulating appli- 
ance in position. The orthodontist has been at work and 
these appliances have been in place more than three months. 
An inflamed area is disclosed at the apex of the cuspid with 
some breaking down of new tissue which is not to be won- 
dered at, considering the movement that has taken place, but 
with positive retention nature will quickly correct this condi- 
tion and the upbuilding will be more rapid, certainly a re- 
markable showing, and surely a convincing proof to the un- 
believer in the successful treatment of pyorrhea by instru- 
mentation. No vaccines or stimulations of any sort has 
been used to assist nature in this upbuilding. In fact, I am 



Tooth Root Absorption. 317 

rather prejudiced against such treatment, my contention be- 
ing that if all the deposits are removed nature will rebuild 
new tissue between the roots, the same as in any other part 
of the body, but the area must be clear of all irritation, not 
only of deposits on the roots but neucrotic tissue in the af- 
fected area, care being taken to currett all rough edges of 
the process." 

Sometimes the process rebuilds around the teeth which 
have been operated on, but in most cases it does not so favor 
us. All we can do is to make conditions favorable for its 
rebuilding. This is best done by the following, Fletcher's 
method, in dealing with the alveolus. This curetment 
gives a beneficial bleeding and starts the bone cells toward 
growth. We may not get complete obliteration of the pocket 
but we have a filling in which holds the tooth much firmer 
than before the operation. Some investigators are now at 
work on this problem and progress is being made. In other 
locations in the body, bone dust can be used successfully to 
fill in lost bone, but the conditions for re-infection here are 
against this experiment. 

TOOTH ROOT ABSORPTION. 

Often on failure to restore a tooth by treatment, we ex- 
tract it and find the end absorbed, leaving a rough margin 
with small sharp projections. (Figs. 81 and 87.) 

I wrote to Dr. T. B. Hartzell asking him to answer the 
following questions relative to the absorption at the end of 
the roots of teeth, especially with respect to the lower cen- 
tral and lateral incisors: 

1st, Why is it that these teeth are more prone to root ab- 
sorption than other teeth? 

2d, How does it occur and leave the teeth alive? 



318 Practical Pyorrhea Alveolaris. 

3d, Is it the same process that occurs with the temporary 
teeth? 

4th, Is there any way of diagnosing probable root absorp- 
tion before it takes place? 




Fig. 87. Eroded teeth in pyorrhea. (C) Tooth treated with acid until 
it was like chalk when extracted. This treatment evidently caused the 
cavity in root for the pocket was in lingual side. (Prom author's 
collection.) 



In answer to these questions Dr. Hartzell wrote me as 
follows : 

"The process of root absorption in teeth that have lost 
bony support is largely due to movement, which stimulates 
osteoclasis. My experience with those teeth is that the more 
rigid they are held in position, the less root absorption. Of 
course there is a certain amount of irritation from bacterial 
poison in all cases, which added to the physical movement, 
further stimulates bone destruction by making perfect the 
conditions for absorption. 

"Did you ever see the two ends of a broken bone in which 
you had a false joint finally established? The ends of such 
bones are rounded and resorbed back. This is the same 
thing which occurs in the socket about the end of a tooth 
that has movement, and also is the same process which de- 
stroys the root end. 



Formation of Pus Pockets, 



3i9 



"No, it is not the same process that occurs with the tem- 
porary teeth. That is a normal physical condition, and the 
process is stimulated in the case of temporary teeth through 
the irritation by the uplift of the permanent teeth against the 
deciduous root end, and happens long before any movement 
can occur in the tooth by reason of its shortened root and 
without infection. 

"Yes, root absorption is always probable where there is 
considerable movement established or where infections are 
resident in the tissues around the root end." 

Dr. Hartzell did not answer the second question, nor has 
anyone else, to my satisfaction. The answer to the fourth 
can be deducted from his remarks. Stop movement by 
treatment and splint. 

FORMATION OF PUS POCKETS. 

The result of irritation to the gingival tissues produces an 
exudation in the gum tissue. This exudate becomes septic 
through the action of the bacteria of the mouth, forming 
pus; suppuration destroys the adjacent alveolus, forming the 
so-called "pockets." 

In the early stages, the extent or depth of a pocket on 
the tooth root is indicated by a reddish area on the gum. 
As the disease progresses and becomes chronic the color 
changes to a purplish hue. The color of the pus from the 
reddish area is yellow; that from the chronic or old stand- 
ing is mixed with stagnant blood and is dark blue, purplish 
or black in color. 

Black has said that the human teeth bear something like 
1700 pounds of pressure each day. If we will liken a tooth 
in its socket to a piston working under a heavy load, we will 
see how easy it is for bacteria and its products to be forced 
into the broken blood vessels found here and the cancellous 
structure of the jaw bone. Estimating the infected surface 



320 



Practical Pyorrhea Alveolaris. 



of a Pyorrhea case, we are surprised to find its extent from 
three to seven square inches. In addition to this, if we will 
compute the quantity of pus and other poisonous products ex- 
creted and swallowed daily by the average case of Pyorrhea, 
something like a half teaspoonful will be a safe average. 
The wonder of it all is that nature can provide immunity 
against such odds. You can safely tell your patients, how- 
ever, that just so surely as they are not immune from death 
and taxes, sooner or later, they are to suffer from this grad- 
ual pumping into the system and swallowing of these poisons. 
Goadby, one of our best authorities in his "Mycology of the 
Mouth," has said: "Small but considerable dosage with bac- 
teria and products from a local focus tends to gradually 
break down immunity." 

ALVEOLAR ABSCESS IN PYORRHEA. 

A narrow constricted pocket may become suddenly very 
active or the exit from any pocket may become blocked to 
form a pyorrheal alveolar abscess. The swelling may have 
some of the appearances of the ordinary alveolar abscess 
from a decomposed pulp, and is often mistaken for such. 




Fig. 88. Typical alveolar abscesses. Note alsorption of root end in 
first picture. Someone answer why this occurs so often at tip of root 
rather than other parts of the tooth. (Author's case.) 



Alveolar Abscess. 321 

Smith has called our attention to the diagnostic points in 
differentiating pericemental abscess and pyorrhea. 

Pericemental abscess is not the result of putrescent pulp 
tissue, but on the contrary, it generally occurs on live teeth 
between the bification or at the end of fused roots. The 
pain is not severe but continuous. There are no inflamma- 
tory symptoms. The discharge of pus is small, oozing to 
the surface of the gum margin; it never forms fistulae like a 
pulp abscess. On extraction these teeth present small glo- 
bules of pus having no confining membrane. (Fig. 88.) 

The constitutional symptoms are very severe as compared 
with the severity of the pathological condition. Nervous 
oppression, indigestion, malaise or headache may result 
from the absorption of pus from these abscesses. 

Smith claims that pericemental abscess is not a state of 
pyorrhea although they are often associated in the same 
mouth. The abcess develops in some inaccessible depres- 
sion between bicuspids or molars, while pyorrhea is found on 
straight-rooted teeth. Smith further claims that teeth af- 
fected with abscess can not be cured except by extraction. 

The soreness, looseness and pus discharge from this class 
of teeth are often mistaken for pyorrhea, and consequently 
unsuccessfully treated. 

Differential diagnosis between pulp alveolar and pyor- 
rheal alveolar abscess: 



PULP ABSCESS. PYORRHEAL ABSCESS. 

Only on dead teeth. Generally on live teeth. 

Comes on gradually. Appears in a few hours. 

Severe throbbing pains. Pain not so severe. 

Swelling extends over consider- Swelling localized on one tooth. 

able area. Color, generally purple. 

Color, bright red. Location, near cervical border 

Location, near root ends. of gums. 

Other points connected with the pathological anatomy are 
intimately associated with and described under the follow T - 
ing pages. 



CHAPTER XXV. 

SYMPTOMS, DURATION, AND DIAGNOSIS OF PYORRHEA. — THE 
V/iLUE OF THE RADIOGRAPH IN PYORRHEA. 

SYMPTOMS. 

As we said in the definition of pyorrhea, it is of slow on- 
set. So slow is it that a patient may have it for years and 
be unaware of his condition until a dentist tells him of it. 
On the other hand, it is a sleeping volcano, liable to break 
out at any time. Suddenly, some day the gums begin to 
swell and the volcano breaks forth with an alveolar abscess. 
You will find that in the incipient stage the patient stops 
brushing his teeth because the gums are painful and bleed. 
In the latter stages you will find the exudation of pus, and 
the teeth becoming loose. 

The symptoms are sometimes so mild that it is difficult 
to diagnose the condition until you have made a thorough 
examination. A physician once referred a case of pyor- 
rhea to me and I reported that I did not think the case seri- 
ous. I failed to make the proper examination. When I 
operated, I found the condition serious in that the alveolus 
was almost disintegrated. 

To know the early signs of the disease one must be very 
familiar with them and always make a careful probing ex- 
amination. The patient may have had pyorrhea before 
he got into the habit of brushing his teeth, so that when he 
comes to you his teeth may be in a clean condition, thus 
somewhat covering up the septic picture and deceiving the 
examiner. 

A rather common symptom of advanced pyorrhea is a 
separation of the teeth, destroying the contact points and 



Symptoms. 



3 2 3 




Fig. 89. Pocket on one side of tooth showing separation of tooth 
toward the side where the peridental membrane is still attached. 
(Author's case.) 



giving entrance for food impaction. The peculiarity of this 
separation is that the affected tooth bears away from the 
point of infection or pocket. At first glance it would seem 
that the tooth would fall over on the weakened side. If we 
imagine the tooth to have rubber bands on both sides, each 
pulling the tooth in the opposite direction, should one be 
cut, we know that the tendency of the tooth would be to 
move toward the side where the rubber remained. Now 
the peridental membrane or ligamentous fibres are the elas- 
tic bands which draw the tooth away from the side where 
pyorrhea has weakened the "sling." (Fig. 89.) 

Mal-occlusion is almost a constant symptom and result 
of oral sepsis. It seems that the teeth are constantly chang- 
ing their position in pyorrhea. One patient had a lower 
cuspid which had turned half way around. Another patient 
had such a wide separation between the two lower centrals 
that a bridge with two extra teeth was required to fill the 
gap. The result in such cases is to destroy the proper 
occlusion. 

One of the most constant symptoms of pyorrhea is the 
odor coming from the pus, which is similar to that from a 
diseased antrum. You instantly detect this odor as soon as 



324 Practical Pyorrhea Alveolaris. 

the patient opens his mouth, and you will soon learn to know 
it. The odor is characteristic. 

The patients will nearly always tell you that they brush 
their teeth from two to six times per day, and that they can 
not understand why their gums should give them any 
trouble. 

The slight general symptoms are not nearly what we 
might expect from such an amount of infection; we are sur- 
prised to have some of the patients state that they suffer no 
other than local mouth symptoms. In other cases they have 
attacks of indigestion and have probably been treated by 
a stomach specialist. 

The patient may exhibit the symptoms of various other 
diseases connected with the eye, throat, heart or kidney 
which may be traced to mouth infection from pyorrhea. 

DURATION. 

The duration of pyorrhea is very uncertain. The incipi- 
ent form, so called gingivitis, may run along many years 
before developing into the more severe types. When an 
infection of long standing does begin to make inroads into 
deeper structure, the progress of the disease is very rapid. 
There are many factors as to health, local mouth conditions 
and character of infection or inflammation which affect the 
duration. 

Individuals who have healthy mouths and who ordinarily 
give proper regard to dental toilet may for some cause, such 
as sickness or severe grief, entirely omit any care of their 
mouths. This lowering of vital resistance together with 
the omission of cleaning the mouth will produce a pyorrheal 
condition giving a history of rapid development. In so 
short a time as thirty days such a case may exhibit bleeding 
gums, pus, and loosened teeth. 

A recent case was that of a young healthy girl of sixteen 
years who, inside of six months, developed such a severe 



Diagnosis. 325 

pyorrhea that one tooth dropped out into the spittoon while 
making the examination. It would have been a safe guess 
to say that in six months more she would have lost many 
of her teeth. This case yielded promptly to treatment with 
the exception of lower central and lateral, which were 
bridged. 

On the other hand, just the opposite history of duration 
is often met with. Patients often answer that they have 
had diseased gums from ten to twenty years. 

From these observations it will be seen that there is no 
regular rule as to the time required for pyorrhea to run its 
course to the stage where there is exfoliation of the affected 
teeth. This much we do know; it never gets better spon- 
taneously without treatment, but always, whether gradually 
or rapidly, is sure to continue to grow worse. 

DIAGNOSIS. 

Dr. Younger has written that "fully ninety-five per cent, 
of the Anglo-Saxon race have pyorrhea in some stage of de- 
velopment in one or more of the alveoli. It is common 
among all races in all countries, and among all classes. The 
rich and the poor, the well conditioned and the mean, the 
vegetarian and the meat eater, the bibulous and the abstemi- 
ous, the fat and the lean, the robust and the debilitated, the 
strong and the weak are all affected. Neither does tem- 
perament seem to produce immunity, for the nervous, the 
sanguine, and the phlegmatic suffer from it." 

I am sorry to say that even though the proportion is 
large many dentists who are accustomed to making diag- 
noses of carious conditions are not able to diagnose a pyor- 
rhea case. Patients often complain that the dentist did not 
tell them that they had pyorrhea. Some dentists may at 
times recognize the condition but not attend to it. In other 
cases the disease has not received the proper treatment, 
meanwhile growing worse, and valuable time is lost before 



326 Practical Pyorrhea Alveolaris. 




Fig. 90. A typical case of pyorrhea alveolaris due to simple neglect. 
The engraving does not show the dark blue color of this congested gum. 
The serumal calculus in this case is as hard as the tooth structure. 
Very little pus present and teeth all firm. 



the patient is finally referred to a dentist or specialist who 
can cure pyorrhea. 

The time is passing when a well informed dentist will 
limit his diagnosis of pyorrhea to what he sees in the mouth. 
Dr. Arthur H. Merritt wrote me recently that he believes 
"still more attention should be paid to the general health 
of patients, and very careful histories made, such as urinary 
analysis, blood counts, (including a differential), blood pres- 
sure, Wasserman test when syphilis is suspected, radio- 
graphs, etc. Constipation seems to be associated with bad 
pyorrhea conditions and should be looked for and cor- 
rected." 

Often grave responsibility is attached to our diagnosis. 
For instance, Anglii calls attention to cases of ulcerative 
gingivi-stomatitis due to Vincent's bacteria. These cases are 



Diagnosis. 327 

said to have a close resemblance to diphtheria, while the 
mouth complication may be pyorrhea. This infection is 
found between the teeth or in inaccessible places. The in- 
terproximal gum tissue and alveolus undergo a quick necrotic 
destruction. The diagnostic points are: the gray color 
which when rubbed off leaves a bleeding surface which will 
reproduce within two hours much pain and loss of gum fes- 
toon. Positive diagnosis must be made by microscopical 
examination. 

Some other conditions with which we should be familiar 
in making a diagnosis are syphilis, leucoplakia and tuber- 
culosis. I will not go into a detailed description of these 
diseases; but just a point or two is given bearing on the diag- 
nosis from pyorrhea. The initial lesion of syphilis produces 
a round oval nodule on lip or tongue which in color resem- 
bles that of boiled ham. The size may vary from that of a 
large pin head to a ten cent piece. They are always pain- 
less and indurated. In syphilis itself the alveolus may come 
away as a sequestrium because the circulation is cut off to 
such an extent that the pulp and surrounding structure may 
die. In diagnosis we must contrast this rapid destruction 
with the slow disintegration of the alveolus from the gin- 
gival border towards the apex which we find in pyorrhea. 

Leukoplakia is a rare condition, but should be suspected 
if gums and cheeks present small, pale colored patches which 
are slightly indurated. 

Tubercular conditions are likewise of rare occurrence in 
the mouth. When present, we have small yellow granular 
nodules which are located mostly in the posterior part of the 
mouth and pharynx. 

In making a diagnosis of pyorrhea, we must not only 
know the physical symptoms but go beyond the mere mouth 
conditions. As suggested by Dr. Merritt the general his- 
tory of the patient must be taken into account when a diag- 
nosis is given. By the routine use of a history chart many 



328 Practical Pyorrhea Alveolaris. 

interesting and valuable facts for the diagnosis of pyor- 
rheal conditions are brought out which will have a bearing 
on the treatment. 

THE RADIOGRAPH IN RIGGS' DISEASE, BY ALONZO 
MILTON NODINE, D.D.S. 

"The use of the X-ray as a means of diagnosis in cases of 
pyorrhea alveolaris is quite as essential, quite as valuable 
as in any other field of dentistry. That the X-ray is not 
more generally used by those who are making the treatment 
of this disease their special work is to be deplored. If 
specialists realized and appreciated the vast amount of 
doubt, disappointment, dissatisfaction, mistrust and wasted 
effort for which the failure to employ the X-ray is responsi- 
ble they would not have that unbounded faith, which they 
now have, in their unassisted visual and digital examina- 
tions. 

"As a form of treatment, the X-ray has doubtful, if any, 
value. The mode of application to any part of the mouth, 
except to the incisors and canines is fraught with such diffi- 
culties as to be impractical were it desirable to use them. 
The element of danger in the continued treatments with the 
X-ray also precludes their employment for the treatment of 
this disease. Taking everything into consideration, the 
chief and perhaps the only value the X-ray has in the field 
of the Riggs' Disease specialist is the taking of the radio- 
graphs for diagnostic, record, and research purposes. 

"That the X-ray is an infallible guide must not be enter- 
tained for a minute, but all symptoms, signs and hints, taken 
in conjunction with the radiographic examination, will make 
the diagnosis more clear and positive. 

"The most apparent use to which the X-ray may be ap- 
plied is to find out the amount of bone destruction or absorp- 
tion about the roots of the teeth afflicted with Riggs' Dis- 
ease. Instrumental examination is about as exact and certain 
as the complete filling of root canals without a radiograph. 



Radiograph in Rigg's Disease. 



329 



How certain that is, may be judged from the fact that less 
than five per cent, of the roots into which root canal fillings 
are placed reach the apex. 




Fig. 91. (A) Case of pyorrhea showing absorption of roots, compli- 
cated with apical abscess. (B) Case with extensive absorption compli- 
cated with periapical abscess. (C) Apical abscess on palital root of first 
molar, apical infection on first bicuspid and eroted root of first bicuspid. 
Note extensive pocket between scond and third molars. (D) Pyorrhea 
with excementosis. (E) Pyorrhea, excementosis and eroted roots. (F) 
Excessive absorption of bone also showing deposits on roots. (Nodine.) 



330 Practical Pyorrhea Alveolaris. 

"The radiograph will not only show the amount of ab- 
sorption of the alveolar bone, but will, within certain limits, 
show the state of the attachment between the alveolar bone 
and the tooth. It will also show the length of the root and 
the amount of leverage it may stand. 

"How great a help this is will be well understood by those 
who have treated cases of Riggs' Disease, believing, from 
examination without the X-ray, that there was sufficient 
alveolar bone about the tooth to justify its retention or that 
the tooth was sufficiently long or strong to withstand lever- 
age, or that the attachment between the bone and the tooth 
was sufficiently secure to yield to treatment; then after the 
most expert instrumentation and medication the teeth came 
out within a short time ! 

"The most common mistake made by those who treat 
Riggs' Disease without using the radiograph is that of treat- 
ing chronic alveolar abscesses for Riggs' Disease. The 
number of cases in which chronic alveolar abscesses dis- 
charge their pathological contents between the proximal sur- 
face of teeth is exceedingly great. And this simulates Riggs 
Disease so closely that it is a continual puzzle to those who 
treat this disease why such teeth fail to respond to treatment. 
This condition of affairs is not confined to the anterior teeth 
or bicuspids, but also includes the upper and lower molars. 

"The presence of undiscovered blind abscesses is also an- 
other condition that confuses both the diagnosis and the 
treatment of Riggs' Disease. Such teeth having lowered 
both the systemic and local resistance, the efforts of the den- 
tist to restore normal tooth function and overcome the gen- 
eral infection, supposedly due solely to the Riggs' Disease, 
are defeated and nullified by the constant and insidious in- 
fection produced by these apical abscesses. This suggests 
that any teeth to which are attached caps, crowns or bridge- 
work, or any devitalized teeth should be subjected to radio- 
graphic examination prior to treatment. 



Radiograph in Riggs' Disease. 331 

"The frequency with which, after prolonged treatment 
and supposed cure, teeth come out, whose roots are absorbed 
or eroded, is another state of affairs that the radiograph 
would largely have foreseen. The wasted effort, the dis- 
appointment and dissatisfaction for which this is responsible 
is very great. Roots whose apicies are as sharp as pins, 
roots which have been eroded or corroded, are left in the 
mouth to be a continued source of infection and irritation. 
They are beyond the hope of cure, and delay the restoration 
of healthy conditions about teeth which may be saved. 

"Not a few teeth about which Riggs' Disease is exerting 
its malignant influence have undergone the process of exce- 
mentosis. The extent of this excementosis often is so great 
that it calls for the extraction of the tooth or teeth. The 
difficulty of treatment, and confusion that such an added 
pathological condition entails on the dentist makes this one 
of the most serious problems that confronts him. 

"Since the treatment of Riggs' Disease resolves itself into 
a re-organization of the mouth, and an attempt to restore 
function to as near normal as possible, the employment of 
the radiograph will be found to be the most valuable and 
trustworthy guide we have to help attain this end. It is a 
continual surprise and wonder to those who now use this 
agent as a diagnostic help to find those unsuspected and 
strange conditions which only the radiograph or autopsy 
could reveal. 

"Hundreds of radiographic examinations by the writer 
force upon him the conviction that he and others who 
hitherto have not used the radiograph have been indulging 
in some very wild speculation and guesswork. This has en- 
tailed a vast amount of useless effort, and, in many cases, 
harmful effort. 

"When we review the great number of conditions that 
may produce chronic irritation and lay the foundation for 
Riggs' Disease, it will be realized that a radiograph exam- 



332 Practical Pyorrhea Alveolaris. 

ation is of such value as to be almost indispensible for any- 
where near a proper diagnosis. 

"At first thought, we have such confidence in our ability 
to see with our eyes and feel with our fingers that the X-ray 
seems unnecessary. But even the most expert fail to find, 
and often overlook, what the X-ray does find. The greater 
experience one has had with the X-ray, the more convinced 
one becomes that one's ability to discover by any other means 
the conditions that the radiograph reveals is greatly over- 
estimated. 

"It is only necessary to name some of the things which, in 
the treatment of Riggs' Disease, have been overlooked by 
the eye and the instrument! For example, pieces of tooth 
pick, gutta-percha, amalgam and cement pushed up between 
teeth, broaches, bits of broken instruments, ligatures, and 
rubber-dam have been found: perforated roots with the post 
of a porcelain crown sticking out, lost or forgotten roots 
and impacted teeth causing chronic and persistent irritation. 

"Often, with all conditions quite right, as the tube, expo- 
sure and angle of the rays, it is possible to find deposits on 
the roots and pulp stones in the canal. 

"It is quite advisable, if not necessary, to have a radio- 
graphic examination before beginning treatment as part of 
the diagnosis. It is also well, after the treatment is com- 
pleted, to again examine with the X-ray as a matter of rec- 
ord. After a year or two it is quite interesting to again 
examine with the X-ray to find out if regeneration of the 
bone has taken place." 



CHAPTER XXVI. 

PROGNOSIS.— BLOOD PRESSURE.— ARTIFICIAL 
TEETH IN REGARD TO PYORRHEA. 

PROGNOSIS. 

The questions that patients ask the dentist when informed 
that they have pyorrhea are, "Can you cure it, Doctor? 
Will it stay cured? Do you guarantee a cure?" 

To the last named question the dentist should always be 
prepared with an answer and, though he might gain a little 
more business by saying that he could guarantee a cure, still 
the time may come around when he will regret having told 
the patient this. One dissatisfied patient can do a dentist 
a great deal of harm. He should be told that to "guaran- 
tee" is only to make use of a catch phrase used by dental 
parlors and shyster physicians. Patients would not think 
of asking a physician to guarantee a cure of typhoid fever 
or grippe or ear trouble, before accepting his services. The 
patient with pyorrhea must understand that there are so 
many conditions on which our success depends that a cure 
can not be guaranteed. Then again, we are not in the in- 
surance business; nature could not make teeth with a guar- 
antee that they would stand, certainly we should not be ex- 
pected to. One way to get out of all arguments of this 
question is the method I use in my office. On the examina- 
tion sheet, I have printed at the bottom the information that 
"we do not guarantee any operations." The patient at once 
sees this and all questions along this line are generally 
avoided. 

To the query, "Will it stay cured?" we can answer a 
little more definitely. If we have diagnosed the case prop- 
erly, and accepted it, we can tell them with some degree of 



334 Practical Pyorrhea Alveolaris. 

certainty that where the proper degree of oral hygiene is 
carried out, and where repeated visits at stated intervals are 
made to the dentist, for the purpose of having the teeth 
cleaned and polished (systematic prophylaxis), that they 
should not only stay cured but the condition of their mouths 
should improve with every visit to the dentist. In other 
words, if the operation is successful, and the patient masters 
the proper technique of keeping the teeth and gums in good 
condition, the mouth conditions should improve all the time. 

The nose and throat specialists will not tell you that they 
cure catarrh. They cure the local conditions, the patient 
gets along nicely, until he exposes himself or contracts a cold, 
then he is in the same condition as before treatment. Now, 
the same analogy applies to the treatment of pyorrhea. We 
certainly can cure the condition, and, as long as the patient 
carries out our instructions, he will get along fairly well, 
but if he fails at any one point, he loses out, still, we are in 
the same position as the Rhinologist, we can cure it again. 
The only difference is that the patient will gladly pay again 
for medical treatment, but thinks that a return of Pyorrhea 
is entirely on account of failure of the first treatment and 
expects all future treatments free of charge. This is not 
a rare experience by any means. 

The question as to the curability of pyorrhea is one which 
has been freely discussed by dentists, and on it has hinged 
much of the criticism of experts and specialists in pyorrhea. 
If you mean by "cure" that the bony structure will rebuild 
and will be restored to its normal bulk around the teeth, 
if you mean that the gums will grow back to their normal 
position at the juncture of the enamel and root of the teeth 
and with the same degree of firmness as heretofore, and if 
you mean that the patients will be able to go as other people 
with just ordinary care of their mouths, then we would have 
to admit that a real case of pyorrhea alveolaris is never 
cured. Of course, in mild and incipient cases of pyorrhea, 



Prognosis. 335 

all this does not apply, but we are referring to the more 
advanced case. Remember, in giving your prognosis, that 
the patient expects the gum tissue to grow up to its original 
position at the juncture of the enamel and the dentine, there- 
fore it should be explained that the gums will probably 
shrink from the teeth even more, for this is one result of a 
successful pyorrhea operation in that tumefaction is re- 
duced. 

In answer to a question about the cure of alveolar pyor- 
rhea Dr. Arthur E. Peck writes: 

"If the treatment for pyorrhea has been thorough and 
the removal of pyorrheal deposits has been accomplished, 
the case is then cured. The burden of maintaining a cure 
after the treatment of pyorrhea rests largely with the den- 
tist. The hearty co-operation and support of the patients 
must be secured. They should be taught how to keep the 
teeth and gums clean and healthy. They should be im- 
pressed with the importance of having a prophylactic treat- 
ment at certain intervals. This prophylactic treatment re- 
quires as much skill or even more than the original treat- 
ment of the case, as the slightest particle of returning de- 
posit must be removed and to detect this small particle tests 
the ability of the most skilled operator. The loose teeth 
must be made immobile either with pyorrheal splints or 
bridge work. The occlusion must be so regulated that un- 
due pressure will not be brought on the affected teeth. If 
these few instructions are followed accurately the prognosis 
is good for a cure in nearly every case where the bony sup- 
port is sufficient to prevent the tooth from being easily ro- 
tated or from cushioning' on pressure. " 

The question as to the curability of a given case is one 
which depends a good deal on the individual skill of the 
dentist. A case may be incurable in the hands of one prac- 
titioner and easily cured by another, who is more skillful 
in the removal of pyorrheal conditions. 



336 Practical Pyorrhea Alveolaris. 

By proper treatment, pyorrheal conditions can be healed, 
the tumefaction of the gums and soreness of the teeth can 
be made to disappear. The shedding of the teeth, flow of 
pus, elongation of the teeth, recession of the gums, carious 
action in the bone and its resulting odor can be obliterated. 
These are the benefits to be derived from the treatment of 
diseased gums. Not only this, but we can also prevent 
other teeth in the same mouth from becoming infected. 

In regard to the curability of pyorrhea, Dr. Hutchinson 
says: 

"The great majority still believe it to be incurable, and 
progress is being seriously hampered by the influence of 
those who persistently refuse to believe what some of us 
know to be true. . . . The fact that the majority have 
failed in their efforts to cure pyorrhea has had greater 
weight than the successful effort of the few. ... I 
have frequently been told by patients that some friend of 
theirs, at their solicitation, had intended to have treatment 
for pyorrhea, but had abandoned the idea because the den- 
tist had told them that it was a constitutional disease and 
could not be cured. No man has the right to deprive the 
patients of a benefit because he either can not render the 
service or is ignorant of the fact that it can be rendered. 
If any practitioner fails in his attempts, he must 
not conclude that a cure can not be effected. If he fails, 
there is a good reason for it, and he may succeed later on." 

The dental profession has been responsible for the loss 
of thousands of teeth just because so many dentists have told 
their patients that there is no cure for pyorrhea. If den- 
tists have such large practices that they do not care to take 
time for the treatment of these cases, it is well for them to 
know that other men in the profession are making a success 
of this work and that from 75 to 85 per cent, of all cases 
of pyorrhea are being cured and stay cured under the care of 
these operations. I do not make this statement from mere 



Prognosis. 337 

hearsay nor from what other men have written. In addi- 
tion to my own experience in treating these cases, I have 
been in the offices of other specialists and have seen numbers 
of patients who have been cured. This will be discussed 
again at full length; but let no dentist be again guilty of 
saying that pyorrhea operations are failures, for it is up to 
us and up to the dental profession to stop this horrible in- 
crease of oral sepsis. 

The following extract from a paper of Dr. A. H. Mer- 
ritt gives in a concise form the prognosis of pyorrhea and 
what we can do and expect in our treatment of mouth in- 
fections: 

"Pyorrhea is a preventable disease, probably the most 
easily preventable of all those occurring in the mouth. It 
is also a curable disease, though every case will, if long 
enough neglected, reach an incurable stage. The prognosis, 
therefore, depends largely upon the stage to which the dis- 
ease has progressed. 

"Inquiry should always be made regarding the patient's 
general health and habits of life. In all cases where a con- 
stitutional relationship is suspected, a careful physical ex- 
amination should be made, and the co-operation of the fam- 
ily physician sought. With our present limited knowledge 
of these relationships, dependence however must be placed 
upon local treatment. When this is skillfully done, the re- 
sults are most gratifying. The discharge of pus ceases, the 
gums resume their normal color, the teeth tighten in their 
sockets, and the patient is able to use them more or less 
freely. When not too far advanced, the disease can be 
permanently cured by such treatment. 

"There are, of course, incurable cases, and what is more 
frequent, teeth that are incurable in mouths where many 
of the teeth are only slightly involved. It is not always 
easy to determine when a given tooth is incurable, and the 
attempt is often made to save such teeth with discouraging 



338 Practical Pyorrhea Alveolaris. 

results to both dentist and patient. When in doubt, the 
tooth should be radiographed. 

"When the dental profession realizes that pyorrhea is a 
preventable disease; that in its early stages it is easily and 
permanently cured; that only those cases are hopeless that 
are long neglected; that no drug or vaccine ever will of itself 
cure the disease, and that dependence must be placed upon 
local treatment, they will have taken the first step towards 
the elimination from the mouths of their patients the chief 
of mouth infections." — (Taken from a paper read before 
the Massachusetts State Dental Society at Boston, May 6th, 
and published in The Journal of Allied Dental Societies, 
June, 1915.) 

In giving our prognosis to the patient, we should bear in 
mind that the disease in the upper jaw is more amenable to 
treatment than in the lower. In the first place the structure 
of the teeth and jaw favor this and they are more easily 
operated on in the immovable upper jaw. In addition to 
this, they are not subjected to the movement of the muscles 
and are not constantly immersed in the re-infecting saliva. 
On the other hand, the prognosis should be much more 
guarded if the disease has taken hold of the lower jaw. 
Here all the secretions are constantly coming into the pocket 
that we are trying to heal, and it is difficult to keep the 
medicaments that we apply in place for any length of time 
so as to get their full effect. 

If the patient can be operated on before any destruction 
of the supporting tissues, so much the better, but in those 
cases where this has occurred to any considerable extent, 
even though an operative procedure might for the time being 
tighten these teeth, it would be better to extract them at 
once. 

On the question of bony support, Smith says: 
u The permanent tightening of teeth which have been 
loosened from pyorrhea, is wholly dependent on the amount 



Prognosis. 339 

of support remaining in the alveolus and the life of the 
cementum. 

"If the destruction of the pericementum caused by the 
necrotic wasting of the alveolus has not progressed too far, 
the tissues about the loosening teeth may, by intelligent 
treatment, be made to close in upon the roots and thus to a 
greater or less degree, they will tighten in their sockets. 

"Terminal alveolar tissue once necrosed and wasted can ■ 
never be restored, this tissue can not be made to renew or 
build itself, neither can it be made to build around the roots 
of the teeth, therefore, the cure of pyorrhea is not neces- 
sarily followed by permanent and satisfactory tightening 
of all the teeth under all conditions." 

Another point in giving the patient a prognosis will be the 
probable condition of vitality of the peridental membrane. 
If the disease is in such an advanced stage that this structure 
has become saturated with infection, or its nutrition is to 
any degree affected, the chances of our being able to make a 
complete cure are correspondingly lessened. 

Dr. J. J. Sarrazin in "Items of Interest" for March, 19 15, 
reports a case which ended fatally. In writing the author 
relative to this article, he says "this is the first certificate of 
death issued in this country (possibly in the world) where 
the original infection from Riggs' pockets was recognized 
as the primary lesion eventually causing death." 

In case the teeth are loose, be guarded against prognosis. 
In other words, you can not always give a correct prognosis 
in such a case. If the tooth can be moved from side to 
side, it is not so bad, but if it has that "squashy" sound and 
you can move it up and down in its socket, the tooth might 
as well be extracted. The ends of these "squashy" teeth 
often look as if a rat had gnawed them. 

When we find the tooth which can be raised up and down 
in its socket we are led to believe that there is little life in 
the membrane surrounding the tooth, and that the terminal 



340 Practical Pyorrhea Alveolaris. 

end is covered with spicules and burr-like projections. When 
such teeth are extracted, their ends resemble a log on which 
barnacles have collected. Other conditions might produce 
this loosening of the ligamentous attachment, as when the 
tissues at the apex of the socket have become so infected 
that the ends of the root undergo a process of absorption 
similar to the absorption of the temporary tooth. If either 
one of these conditions can be diagnosed beforehand, we can 
say with absolute certainty that the tooth can not be saved. 

BLOOD PRESSURE. 

Clinical medicine now demands that the blood pressure 
test be used in examinations to indicate renal or heart trou- 
bles. It is required in examinations for life insurance, army 
and police departments. 

Only lately have dentists begun to realize its importance 
in regard to the diagnosis, prognosis and treatment of 
pyorrhea. 

Blood pressure readings are useful to dentists because they 
give information about arteriosclerosis, chronic nephritis, 
uremia and plumbism. In these we find the pressure high 
while in the following named diseases we read a low pres- 
sure: anemia, diabetes, starvation and exhaustion. 

The average pressure of males should be 120, at the age 
of 20. For each two years above, one millimeter should be 
added. Thus at the age of 30 the reading should be 125. 
In women we find all readings about 10 millimeters less. 

Simple inexpensive instruments are now on the market 
and have proved their value in pyorrhea work. 

ARTIFICIAL TEETH IN REGARD TO PYORRHEA. 

Every dentist who treats pyorrhea is frequently met with 
the argument that "it is just as good to have a set of arti- 
ficial teeth and much less trouble than trying to save these I 
have." Such a patient will often bring along a friend who 



Artificial Teeth. 341 

has a ''perfect set of artificial teeth," and inasmuch as this 
friend may appear quite healthy, it will often take the best 
argument at our command to convince our patient that the 
restoration and preservation of the natural teeth is superior 
to any artificial substitutes. In the first place we will have 
to admit that artificial teeth are better than teeth and gums 
which are diseased and which are not being kept clean. But 
on the other hand, they must consider the mortification that 
they will feel when the teeth are extracted, the inconvenience 
of getting used to the artificial teeth and the danger of fre- 
quent breakage, and of having to stay indoors for days at a 
time while the teeth are in a vulcanizer for repairs. But 
greater than any other consideration is the fact that the bit- 
ing force of artificial teeth is only about one-fourth of that 
of natural teeth and we know that proper mastication of the 
food is of the greatest importance in maintaining good 
health. 



CHAPTER XXVII. 

INSTRUMENTS FOR USE IN PROPHYLAXIS AND 
PYORRHEA WORK. 

Dr. Riggs, of Hartford, is generally credited with being 
the first American to use instruments in the treatment of 
pyorrhea. The instruments he used were very large and 
crude. Some of his original shapes are still to be found in 
the supply houses. 

Considerable evolution has taken place in reference to 
size and shape. From a very few we are now offered sets 
of instruments numbering several hundred. 

Beginners should not be discouraged by the fact that 
pyorrhea specialists, though possessing large sets of instru- 
ments, often wish they had a still greater variety of shapes 
and forms. It is not advisable for the beginner to buy all 
instruments in any one set; he should select a small number 
and add to them as needed and as familiarity with the work 
demands. The success of pyorrhea operations does not de- 
pend so much on the particular style of the instruments as 
on the operator's familiarity and dexterity in their use. This 
is proved by the fact that many of the contributors to this 
book work with instruments made on different principles. 

The dentist in beginning this work should select those in- 
struments which he thinks will fit into the pockets he has 
seen and should not attempt to use the complicated instru- 
ments with crooks and turns, the purpose of which it takes 
experience to appreciate. 

In making a selection of instruments we should bear in 
mind the delicate work required. In addition to being sharp 
and delicate the blade must be extra strong. Probably 
more is required from a pyorrhea scaler than any other sur- 
gical instrument. 



Instruments. 



343 



Younger says, "If but one small speck is left, even though 
it could be framed in the point of a pin, the irritation and 
bacterial infection maintained by its presence would, I think, 
prevent the diseased surface from healing. It is in the de- 
tection and removal of these minute points that skill and 
delicacy of touch are so much required." 

So difficult is the operation, and in order to become effi- 
cient and expert Dr. Hartzell said that on his infirmary 
patients he frequently scaled a tooth and pulled it out to see 
what had been done. Often he found tartar which had 
escaped his instruments. 

Probably the best general class of instruments for this 
work will be those which are used with a push and those 
used with a pull motion. 

The Allport and Kirk patterns are examples of the push 
motion while those of Tompkins and Hartzell represent 
pull motion. The Younger type has a point that can be used 
either push or pull motion. The file type was popularized 
by Smith. Nearly all complete sets now have some instru- 
ments with file points. The users of each variety of instru- 
ments make the claim of greatest efficiency and a minimum 
amount of pain to the patient in their use. 




Fig. 92. The Kirk Dental Scalers. 

The dentate edge prevents lateral slipping. After their use smooth- 
edged instruments should be used to make the surface smooth. 



344 



Practical Pyorrhea Alveolaris. 



The Kirk dental scalers are excellent for removing the 
large deposits of salivary tartar. The claims for their use 
are a minimum amount of lateral slipping and wounding of 
the gums. They are not intended for deep pyorrheal con- 
ditions; but for dense masses of deposit. The wedge- 
shaped points on each blade cause the mass to break into 
small fragments which are thus loosened from their attach- 
ment. When used they must be followed by a smooth-edge 
instrument to remove the smaller particles and to smooth 
the surface. (Fig. 92.) 

At the time when the push motion instruments were popu- 
lar Dr. R. B. Adair revised the Allport type of blade and 
added others. This was the first set having the end of the 
blades concave on the cutting side to better adapt them to 
the contour of the root, while the back was rounded to pre- 
vent unnecessary irritation or wounding of gum tissue. 
(Fig. 93.) 

fi 




13 14- 15 

Adair-Allport Pyorrhea Instruments. 



Instruments. 



345 



The curved plane head was patented by Dr. Geo. Wink- 
ler. Dr. Gartrell, of Washington, introduced points with 
blades to work on the Japanese plane principal. Dr. C. W. 
Jones, of St. Paul, suggested having the points centered 
with the long axis of the handle. Also a method of sharp- 
ening the blades to prevent deep cutting. Dr. Carr took 
these ideas and classified the instruments into a set. 

Dr. T. B. Hartzell has modified some points and by add- 
ing others has produced a most efficient collection. This set 
is probably too expensive for the general practitioner but 
for those who desire to specialize in this line of work it is 
certainly a good investment. 

This suggestion is well expressed by Dr. A. C. Hamm: 
"I wish to disillusion the minds of many of the thought that 
ideal results can not be obtained without the use of the Carr 
instruments, and I draw this conclusion after years of ex- 
perience with the use of these instruments, as well as those 
of other skillfully designed sets. Many of our most success- 
ful pyorrhea practitioners have never used these instruments, 
yet are accomplishing beautiful results. I mention this that 
the general practitioner may not deem it necessary to ex- 
pend several hundred dollars to purchase instruments with 
which at least to treat the milder cases. It is the surgeon 




Fig. 94. Bates' Scalers, Ivory. 



346 Practical Pyorrhea Alveolaris. 

and not the instruments that performs skillful operations, 
though instruments of proper design are essential." 

Dr. A. F. James gives the following reasons for the adop- 
tion of the planing type of instrument: 

"The writer contends that to be successful in this treat- 
ment, the operator must have developed or been taught some 
definite system of instrumentation that will make it possible 
not only intelligently to remove deposits of calculus from the 
root surface, but also to remove the dead pericemental mem- 
brane, exposing the root surface, without making scratches 
or grooves with the instruments. Also, he must have left a 
smooth root surface, without removing more than the outer 
layer of the cementum, under which will be found a denser 
cemental layer, which if not gouged or roughened by instru- 
ments, will afford a protection from further bacterial as- 
saults and will allow the overlying gum tissue to settle closely 
about the teeth, preventing the lodgment of fermenting sub- 
stances or the packing of food into pockets by the force of 
mastication. 

"It is not my intention to say that successful work can not 
be done with any particular set of instruments in the hands 
of a skillful operator; but I maintain that the ordinary scrap- 
ing and filing instruments are often a cause of injury to the 
very root which we are attempting to benefit. With these 
scraping and filing instruments, of which the cutting edges 
are the only points in contact with the tooth, the delicacy of 
touch can not be attained which makes it possible to locate 
the small particles of deposit and know when they have been 
removed. Both with men whom I have watched use such 
instruments, and in my own hands, it has seemed to be an 
operation of bull-headed determination to remove the de- 
posits, trusting to luck for smoothing the root, which is the 
final object to be gained. 

"To illustrate this point, I will cite an incident which oc- 
curred following one of my clinics. An exchange of ideas 



Instruments 



I 




(f 1 


1 


' * 




f 


^ 




f 1 




f 


\ 




on 




r *% 



Fig. 95. The Younger 
Pyorrhea Instruments. 



348 



Practical Pyorrhea Alveolaris. 



with a fellow practitioner resulted in an invitation to visit 
his office and see some of his cases. I was shown some un- 
questionably successful results, work that any man might be 
proud of having done. The instruments used in this work 
consisted of a number of long-shanked delicately constructed 
files, and a variety of scraping instruments, all of which were 
unspeakably dull. Yet, had they been sharp, as the maker 
intended them to be, the tooth would have been too deeply 
cut and injured rather than improved, since a long, flexible 
shank requires pressure in using. 

"When asked for an opinion I was forced to say: 'Doctor, 
you have obtained these good results through the imperfect 
condition of your instruments. Were I to use your instru- 
ments they are in just the condition I should wish them to be; 
their dullness has made it possible to leave smooth surfaces.' 
Sharp cutting instruments remove much of the cementum, 
leaving the tooth in a sensitive state, requiring a lapse of 




Fig. 96. 



The Good Revision of the Younger Pyorrhea Instrument. 
Cleve-Dent. 



Instruments. 



349 



time to correct the injury. This effect rarely occurs where 
a planing instrument is skillfully used." 

The W. J. Younger pyorrhea instruments receive a well- 
merited large sale. They have been condensed and modi- 
fied by Dr. Robt. Good, into a new set, which is in the 
writer's opinion indispensable to any dentist who even 
"cleans teeth." Dr. Good says: 

"These instruments are made thin, so they will pass under 
the gums easily, and I always use them with the 'pull' mo- 
tion, never shoving, because the 'shove' motion will cause 
pain. The entire point is a cutting edge, so that it makes 
no difference at what angle the instrument is held, it will 
cut." 




5 G 7 8 9 10 Jl 12 

Fig. 97. Smith's Prophylaxis Instruments 




13 L4 

Ivory. 



The Smith prophylaxis instruments, and the various modi- 
fications by other dentists and manufacturers are used to re- 
move deposits from the roots and necks of the teeth. The 
smaller oval forms are for opening into the diseased pockets. 
The large blades are for the interdental spaces. The writer 
has the blade of No. 13 of this set made three times longer 
and finds it most excellent to reach deep pockets on the pos- 
terior root surface of molars. The files are used to finish 
with after using other scalers. 

Dr. Towner believes in the file type of instrument and 
gives his reasons in the following quotation: "The use of 
the file in the surgical treatment of pyorrhea alveolaris, and 



350 



Practical Pyorrhea Alveolaris. 



kindred diseases, seems to be productive of more definite 
results than any instrument suggested. It is the most sensi- 
tive, accurate and delicate instrument yet devised. By its 
use one is enabled to develop a remarkable tactile sense, 
thereby being able to judge the condition of hidden surfaces, 
remove deposits, and polish surfaces treated with an unusual 
degree of accuracy. These instruments have an advantage 
which is seldom recognized in that the edges of the blades 
are serated, thereby permitting their use as positive working 
points in constricted bifurcated areas. They are delicate in 
that they clog and become dull sooner than other instru- 
ments, but the extra care necessary to keep them clean and 
sharp is more than compensated for in the favorable results 
attending their use." 



Polishing Files 




«3 * 5 6 7 8 9 10 

Fig. 98. Dr. Towner's Instruments. 



11 IS 



The M. H. Fletcher set of bone curettes and alveolitis 
burs, are fully described in another chapter by the inventor. 
These instruments are for cutting away dead and diseased 
bone about and beyond the roots of the teeth and are not 
styled nor intended for removing calcarious deposits. 

The instruments above described are the ones most gen- 
erally used. There are many others just as efficient for good 
work but nearly all of them are modifications of these stand- 
ard types. As many of the points are made in pairs, or 
right and left, it is advisable, where possible, to buy these 
for cone socket handles. The writer prefers a double end, 



Instruments. 



35i 




Fig. 99. Tompkins' Pyorrhea Files. 



octagon-shaped, hard rubber handle. This saves handling 
so many instruments. This handle can be boiled. The 
shape and size is just right to prevent cramping. Younger 
and Good use the various colored sealing wax knobs on their 
handles for this purpose, while Sarrazin has aluminum 
knobs with set screws, to use on small handles for the pur- 
pose of preventing slipping and cramping of the hand from 
long use. 



CHAPTER XXVIII. 

INSTRUMENTATION. 

STERILIZATION OF INSTRUMENTS AND PREPARATION 
OF THE MOUTH FOR SURGICAL WORK. 

If there is one thing about which the medical man has 
cause to laugh at the dentist, it is regarding the dentist's 
neglect of sterilizing instruments and cleaning the field of 
operation. The colleges are largely to blame because they 
do not lay sufficient stress on these subjects and do not re- 
quire the dental students to practice the proper methods of 
sterilization in their college course. 

The farcical nature of our processes probably does not 
depend so much on a lack of interest or desire to do the 
proper thing, as the lack of knowledge along these lines. 
In ordinary dental work, such as bridge work, crowns, and 
plates, it may not be of so much importance; but when it 
comes to such work as prophylaxis and pyorrhea, it is fully 
as important as in any other surgical work. 

Not long ago it was noted that a professor of oral sur- 
gery in one of our colleges, in consultation, asked his assist- 
ant for a nerve broach, which was handed to him from the 
regular cabinet stock. He dipped it into alcohol for one sec- 
ond and then proceeded to use it, evidently under the im- 
pression that he was using a perfectly sterilized instrument. 
When a teacher makes such errors as this, is it to be won- 
dered at that young dentists make mistakes? 

The simple dipping of instruments into alcohol is not 
effective; the sterilizers that are generally furnished the den- 
tists are also inefficient. They put up a good appearance, 
but further than this they are not worth much. Methods of 



Sterilization of Instruments. 



353 



sterilization are of two kinds, antiseptic and heat. Alcohol 
in a jar shaped like a fruit jar with a screw top furnishes a 
convenient and effective receptacle. The instruments, both 
before and after the operation, must be thoroughly cleaned 
in running water with a clean brush, and then placed in the 
jar just mentioned and allowed to remain there for at least 
five minutes, when they can be taken out, and dried, or the 
alcohol burned off by bringing them in contact with a small 
flame. 

Lysol and bichloride solutions are not to be recommended 
for this particular line of work, because if used strong 
enough to be effective, the mucous membrane of the mouth 
would be injured. Undoubtedly, the best form of steriliza- 
tion yet found is heat. By heat, I do not mean the simple 
dipping of the instruments into hot water, but the whole 
instrument must be boiled for at least five minutes. In the 
summer time, to have a boiling receptacle in our office, is 
not the most pleasant companion. However, it will be 
found to be the best sterilizer; it also gives a good impres- 
sion and is one of the best advertisements a dentist can have 
outside of good work. Undoubtedly, dental manufacturers 
realize this because all sterilizers have the word "sterilizer" 
written in large letters across the front of the apparatus. 

Not only the dentist's instruments and material should be 
sterilized, but the dentist's hands should be rendered as 

Fig. 100. 




354 Practical Pyorrhea Alveolaris. 

nearly aseptic as possible. After they have been thorough- 
ly washed with a good grade of soap and a nail brush, a few 
drops of alcohol should be rubbed into them; this not only 
destroys the bacteria which may have been received from 
the previous patient, but makes the approach to the next 
patient more agreeable. The best way to manage this is 
by means of a shelf suspended above the wash bowl, on 
which is placed a fountain bottle as per illustration (No. 
ioo). This is filled with grain alcohol, to which may be 
added some good toilet water. 

CLEANSING THE FIELD OF OPERATION. 

Peroxide of Hydrogen is a good agent to be used in mop- 
ping out the mouth. It can be applied by use of a cotton 
swab held by Skinner's "Kuoris." If it is not desirable to 
use peroxide, which is unpleasant to say the least of it, we 
can substitute a solution of aromatic spirits of ammonia, 
one part in five parts of water. This used as a spray or 
on a mop is very efficient for cutting loose the thick mucus 
covering the inside of the mouth, and at the same time, it is 
very cooling and pleasant for the patient. Next the gum 
surfaces and the infected area may be coated with Buckley's 
Pyorrhea Astringent, but preferably with Skinner's Disclos- 
ing Solution, previously described. The ordinary tincture 
of iodine is not so pleasant nor does it remain on as long 
as the Skinner's Disclosing Solution. If the mouth has been 
thoroughly mopped out, the antiseptic solution applied over 
all the surfaces, and the debris removed from open cavities 
which are filled, temporarily, with sandarac varnish and cot- 
ton, or with gutta-percha, we have done about all that is 
possible towards rendering the field of operation sterile. 

A TECHNICAL DESCRIPTION OF THE SURGERY OF THE 
ROOT SURFACE, BY DR. THOMAS B. HARTZELL. 

u In undertaking to write an article descriptive of the tech- 
nical procedure, which must be observed in successfully 



Surgery of Root Surface. 355 

treating pyorrhea, I realize that I am undertaking a very 
difficult task. To portray in words or visualize technical 
procedure, is always difficult, but by the help of word pic- 
tures and illustrations together, I hope to be able to convey 
a comprehensive idea of the operation. 

"The necessity for root surface surgery is now so thor- 
oughly understood that we need not discuss that phase of 
the question at all, though it will be wise to discuss the his- 
tology of the root surface in order that we may have a rea- 
sonably clear idea of the necessity for the operation, and 
also that we may know how much of the root surface we 
should remove and where the cutting should stop. 

"The root is suspended in its socket, as we all know, by 
fibres of sharpey; these fibres originate in the alveolar 
process. When the bone of the process is lost from any 
cause whatever, then these fibres hang dead upon the root 
surface and their decaying remains afford culture media 
in which micro-organisms may rapidly grow and accumu- 
late. The root surface is, therefore, uneven and pitted with 
thousands of small depressions. These depressions were 
occupied by fibre ends, and offer to the eye, when observed 
under the microscope, a honey-comb like surface. 

"The operation on the root surface may involve two 
things: First, the removal of any calculus deposited upon 
the root surface; and, second, the removal of the pitted 
root surface itself. Observing the structure of the root, 
from the pulp chamber outwardly, we note first that dental 
tubuli form the great bulk of the root. Just external to the 
tubuli, we may note a layer of typical bone which contains 
thousands upon thousands of lacunae connected by branch- 
ing canaliculi. Approaching more nearly to the surface of 
the cementum, we see that the lacunae and canaliculi become 
fewer and fewer until the root surface is almost reached, 
at which point we note a narrow zone of bone which con- 
tains neither lacunae nor canaliculi. This dense layer is not 



3 56 Practical Pyorrhea Alveolaris. 

clearly defined as something that could be stripped up and 
peeled off, but, nevertheless, nature seems to have deposited 
this thin layer of hardened bony material as a foundation 
into which the Sharpey's fibres insert to form the suspensory 
ligament which is the sling or stirrup by which the tooth 
rides in its socket. 

"The object of skinning the root surface is to rid that 
root surface of its bacterial holding power. Therefore, the 
amount of root surface which may be cut away with benefit 
to the tooth is that portion external to this dense layer which 
was created to support the fibre ends. And, because of the 
fact that this dense layer is very thin, one should guard care- 
fully against cutting enough of it away to open the bone 
cells which are so plentifully distributed in the body of the 
cementum. Therefore, one should work with instruments 
so designed as to make it impossible in any single stroke to 
penetrate this hard layer. 

"The instruments should be so designed as to offer the 
greatest amount of steadiness and accuracy of movement. 
To that end, it is desirable that the cutting bit, which is used 
to skin off the porous surface, should be flat and thick and 
sharpened to a right angle. It is also desirable that the in- 
strument should rest on at least two points, rather than on 
the cutting edge alone. If the instrument's bit rests upon 
the cutting edge and that portion of the shank immediately 
contiguous to the cutting edge, we have the so-called two- 
point rest instrument, which certainly offers greater security 
and accuracy of movement than a razor-edged, one-pointed 
instrument possibly could afford. The following is an illus- 
tration of the instrument to be applied to root surfaces. 

"On account of the unevenness of the root surface and on 
account of its convex and at times concave character, it is 
necessary to have instruments which can be readily adapted 
to convex surfaces as well as to concave flat surfaces, in 
order to accurately skin every bit of dead membrane pitted 



Surgery of Root Surface. 357 



Fig. 101. The Hartzell Type of 
Instruments. 



358 Practical Pyorrhea Alveolaris. 

surface from any given root. This necessity at once creates 
the demand for three types of plane-heads. By the word 
"plane-head," I mean to describe the cutting bit and the 
portion of the shank immediately contiguous to it, which 
makes the two points of contact to the root, which must or 
should be in contact with the root surface as the instrument 
is moved. The plane-head, therefore, is to the tooth's 
root plane just what that portion of a carpenter's plane is, 
which is immediately in front of the cutting bit. It limits 
the depth to which the cutting bit must penetrate the tissue, 
and, as stated a moment ago, we need three types of plane- 
heads for ordinary tooth root surface surgery: concave 
plane-heads to fit convex root surfaces; convex plane-heads 
to fit concave root surfaces; and flat plane-heads to fit con- 
cave root surfaces; and flat plane-heads to fit flat root sur- 
faces. This at once necessitates three types of plane-heads 
in any efficient set of instruments for root surface work. 
To that end, the author divides the instruments into three 
groups for these three types of surfaces. 

"The next necessity, which the operator feels keenly, to 
fit the first right molar of any given patient, two and six 
designed to present a pair of blades which will fit the mesial 
buccal and distal lingual surfaces of the molar in question. 
Three and seven of this group of eight present a pair, which 
fits the buccal and lingual surfaces of a patient's right lower 
molar. Four and eight constitute a fourth pair designed 
to fit the distal buccal, and mesial lingual surfaces of a right 
lower molar. 

"It does not necessarily follow that the operator need use 
every instrument of any given group of eight to plane a 
lower molar, but it is exceedingly helpful to have the instru- 
ments so planned as to make it possible to approach at least 
eight different aspects of any tooth in the mouth, without 
changing finger rest, if the operator so desires. 



Treatment — Dr. Patterson. 359 

"A fifth essential is that in all of the instruments of what- 
ever type, concave, convex, or flat, long, medium, or short, 
for operation far back in the mouth or almost straight or 
slight bend for operation in the anterior part of the mouth, 
or for what particular tooth or surface an instrument is in- 
tended, the cutting blade of the instrument should be di- 
rectly in line with the center of the handle. This makes 
every instrument, no matter what bend the shank may have, 
in effect a straight instrument." 

TREATMENT OF PYORRHEA ALVEOLARIS, BY DR. 
JOHN DEANS PATTERSON. 

(From Johnson's "Operative Dentistry," by permission of P. 
Blakiston's Son & Co.) 

"In beginning the operation of scaling, it is wise to select 
only that number of teeth for one operation which can be 
entirely finished at one sitting. If the disease is in the in- 
cipient stages, frequently a number of teeth can be treated; 
if the condition is in the advanced stages, from one to four 
should be the limit. In all cases each operation should be 
limited to an hour, for, in the first place, whatever the means 
used for obtunding, the operation is more or less painful; 
the teeth operated upon are also left in a condition acutely 
sensitive to thermal changes, and if many teeth are treated 
at one sitting, the discomfort is distressing for many days 
on this account; so it is surely best to confine this discomfort 
and the painful scaling to a limited time and a limited area to 
prevent accumulated discomfort in cervical territory on ac- 
count of thermal irritation, and to prevent shock from the 
unavoidable pain of the operation. With the correct diag- 
nosis as to the extent of the disease and the selection of the 
suitable instruments, there must be a determination upon the 
part of the operator that the roots selected to be operated 
upon at any sitting shall be entirely freed from irritating 
deposits and the surfaces left in a condition to encourage 



360 Practical Pyorrhea Alveolaris. 

the new tissue of repair to form. The surgical part is not 
complete upon the removal of deposits, but after that these 
surfaces should be smoothed and polished as perfectly as 
may be. About the crowns and the cervix of the tooth en- 
gine instruments with brushes, strips, rubber cones, etc., of 
a great variety of shapes, are applicable; beyond the gum 
margin hand instruments must be used. The various wood 
and other points, held in suitable porte-polisher and charged 
with an abrasive, must reach all possible surfaces. Experi- 
ence has taught that the time spent in smoothing the roots 
is well worth the endeavor, for the rapidity and permanency 
of recovery is greatly enhanced, and the operation can not be 
considered completed until as much time is given to the pol- 
ishing as to the removal of deposits. 

"The polishing concluded, then comes the removal of all 
loosened detritus with the hot water used in a strong force 
syringe with slender special points which will reach well 
down into the pockets; these points are best made of silver 
or German silver, and can be fashioned by any instrument 
maker. 

"If the operation has been well done, it is inadvisable 
to disturb the pockets, which are soon filled with the plasma, 
out of which repair comes. The very common practice of 
frequent probing and medicating is strongly condemned." 

THE SARRAZIN TREATMENT. 

Dr. J. J. Sarrazin has worked out an elaborate system 
of prophylaxis and pyorrhea treatment. The Dental Cos- 
mos (May, 1 9 10) gives his system of treating pyorrheal 
conditions. From this article I quote: 

"There are two ways of handling a jaw which is affected 
generally by the disease. One is to begin at the most pos- 
terior tooth on one side and stop at the median line; then 
continue by starting at the most posterior tooth on the op- 
posite side and again come to the median line. This has 



The Sarrazin Treatment. 361 

the advantage of allowing time for molars on one side of 
the mouth to lose much of their tenderness before the molars 
on the opposite sides are made too sore for mastication. 
The second way will grow out of aggravated conditions in 
some localities, in which instances the operator will see that 
such places must be operated upon at the start, so that ample 
time may elapse to watch their behavior while the surgical 
treatment is being continued elsewhere. 

"I am partial to pull-cut instruments for accomplishing 
just exactly what is wanted on roots. On a smaller scale, 
the motion of such instruments should be more like that of 
a vulcanite scraper on a plate, and still more similar to that 
ol a pencil eraser on paper, the push stroke being much 
lighter, and not like that of a plane on wood. Instrument 
points should be so directed as to operate on only a small 
speck of a root surface at a time, making sure of having 
completely scaled that point before passing to an adjacent 
spot either horizontally or vertically. Such operating should 
be done not only where well-defined pockets exist, but also 
wherever soft tissues fail to closely hug and adhere to ce- 
mentum. If the alveolar tissue be affected beyond diseased 
portions surely lead to it, if they are properly followed. 
On the other hand, soft tissue should be respected where- 
ever it is attached to the pericementum, but instruments 
should reach quite to the lines of such attachments in every 
direction. 

"If operations have been severe, wounds should be fre- 
quently irrigated, just as is practiced in general surgery, 
until such a time as the tissue shows a proper tendency to 
heal. Bismuth paste following such irrigation acts very 
favorably, at the same time warding off the danger of im- 
paction of fermentative material. 

"However thorough the scaling of a single or multi- 
rooted tooth may have been, there is safety in making use 
immediately after operating, of a drug capable of dissolv- 



362 Practical Pyorrhea Alveolaris. 

ing calcareous particles. Wherever the alveolus has been 
seriously affected, greater reliance may probably be placed 
on 50 per cent, sulfuric acid in glycerin, because long clinical 
experience indicates its marked action on hard tissues, with 
a reduced irritation to soft ones." 

FLETCHER'S METHOD OF REMOVING DISEASED 
ALVEOLUS. 

The following quotation is taken from "Alveolitis — the 
Disease of Which Pyorrhea Alveolaris is One Stage," by 
Dr. M. H. Fletcher, printed in the Dental Summary: 

"To operate in any of these cases is surgery and not den- 
tistry, so that the stomatologist also needs to be skillful in 
operative surgery to a degree which gives him suitable 
knowledge and confidence in himself to handle a patient 
undergoing the removal of part of the alveolar process 
either above or below. Further, the operator should be so 
in touch with this patient and the extent of the operation as 
to know whether the operation should be performed under 
local or general anesthesia, and whether it should all be done 
at once or at intervals of a few days or weeks for general 
and systemic complications from secondary and acute infec- 
tion may occur at any time. 

"The curettes or hand instruments are all of the hoe and 
hatchet type, varying only in size of blade and length and 
shape of shank. The attempt is made by these variations to 
reach any extended tract of necrosis. The necrosed portions 
are usually friable — that is, in the state of osteoporosis — 
and can easily be cut away with the curettes; but certain 
phases of the disease and certain kinds of infection often 
result in osteosclerosis; that is, hardened or eburnated bone, 
on which the curettes make little headway. For cutting 
these hardened bones I have made some extra long bone- 
cutting burs, both for the straight and right angle hand- 
pieces. The contra-angle seems to be more suited to the 



Fletcher's Method 




i i i 



/* * 



a a a s s 

12 3 456 789 

Pig. 102. Fletcher's Set of Bone Curettes and Alveolar Burs for 

Cutting Away Dead and Diseased Bone. Not Intended 

for Removing Deposits. 



364 Practical Pyorrhea Alveolaris. 

work, however, than the right angle. The burs for the 
contra-angle will reach all cases in the lower jaw and most 
of the upper, but a bur two and one-half to three inches 
long — that is, one long enough to reach to and into the an- 
trum — is often necessary for the upper jaw. 

"The laws of regeneration do not permit of complete 
healing of bone tissue inside of several weeks at the short- 
est, and often require several months, so that patience and 
careful watching are necessary on the part of both patient 
and doctor. One patient now on my list for nearly a year, 
who would not submit to a radical removal of cancellous 
bone in the superior maxillary, has submitted to a small 
amount of removal from time to time, and is gradually re- 
covering under two dressing treatments a week. This case, 
however, was the result of a dental abscess arising at the 
apex of a superior lateral which had discharged into floor 
of the nose. 

"After curetting and burring have been done, the cavities 
should be washed out with a warm antiseptic solution to re- 
move the cuttings. The blood should be allowed to clot 
in the cavity. My plan is to be careful not to disturb the 
blood clot as long as it remains aseptic. If there is a ten- 
dency for pus to form, the wound should be washed out 
every one, two, or three days, according to conditions, and, 
if pus continues after ten days, a second, third, or even 
more attempts must be made to remove the offending ma- 
terial. 

"Aseptic blood clot is Nature's 'false work' or scaffolding 
on and into which she builds all new tissues, no matter of 
what kind. The less the healthy clot is disturbed, the more 
prompt is the repair. In the blood clot is formed the granu- 
lation tissue of repair, which is the second stage of the 
building of new tissues. Any disturbance to these granules 
is also a hindrance to repair; hence packing is seldom called 
for. 



Dr. LeRoy's Treatment. 365 

"If I have suggested anything new or valuable, I believe 
it is the necessity of either curetting or burring about all 
teeth where the disease is found, and of more thorough re- 
moval, if the disease is deep seated." 

DR. L. C. LEROY'S TREATMENT. 

"There are but two very vital phases in the treatment of 
pyorrhea that I ask the privilege of considering: the surgical 
care of the teeth, instrumentation, and the protection against 
re-infection, particularly where much of the alveolus has 
been destroyed, leaving large interdental spaces. 

"Instrumentation is the "crux" of the entire procedure. It 
must be thorough, the root surfaces must not be impaired, 
and the soft tissues should not be mutilated; in fact, they 
should be left practically uninjured. 

"To fulfill all of the above requires the use of instruments 
peculiarly strong and delicate, for it must be remembered 
that the deposits on teeth roots extend apically below the 
still existing alveolar border as well as coronally. Instru- 
mentation there is the "crux." To be able to place the in- 
strument on or beyond the adhesions at this situation is the 
most important part of the operation. It is within the abil- 
ity of most all operators, with the average scaling instru- 
ments, to remove calculus from the deepest pockets — all but 
that which is in direct contact with the still existing periden- 
tal membrane, which is really the exciting cause of the dis- 
ease. 

"It is the practice and the teaching of some operators lit- 
erally to plane the root surfaces by using instruments, the 
points of which are at right angles with the shanks — scrap- 
ers — which removes part of the cementum. I will not say 
more against such procedure than that, in removing the 
outer smooth cemental lamella, dental caries is the frequent 
sequel, particularly interdentally subgingivally, where it is 
almost impossible to maintain prophylaxis. 



3 66 



Practical Pyorrhea Alveolaris. 







1^1 . - 


?! 




Pig. 103. The LeRoy Type of Instrument Gives the Operator a Very 
Delicate Working Point for Prophylaxis and Pyorrhea Work. 



"The instrument dev-ised by me is a plane in character. 
The relationship of the working point to the surface to be 
operated on is controlled by the "rest" or wrist (see mark- 
ings on cut) , which is very effective in removing adhesions by 
the push stroke, but it must be used with care. The surface 
of the blade just behind the point is serrated, being designed 
to crush calcular adhesions on the pull stroke, which is used 
almost exclusively in the deeper parts. Having located the 
deposits with the tip of the instrument, the procedure is to 
lift the point until it rests on them, put pressure on the shank, 
and pull back with the same movement, thus breaking down 
the adhesions by a crushing process. 

"The working point is bent at such an angle as to just lift 
the serrated surface from the tooth when the push stroke is 
used; but when pressure is applied against the root on the 



Dr. LeRoy's Treatment. 367 

pull stroke, the serrations lie flat against and engage the de- 
posits, and the crushing of them is accomplished. 

"Complicated bends or angles or corkscrew effects have 
purposely been avoided and are generally unnecessary, as the 
deposits on teeth most invariably occur in line with the long 
axis of the tooth and only deflect when the bifurcation of 
the roots or the apex of the root becomes involved. 

"This instrument has extreme delicacy and strength with- 
out being springy. The sides of the blade are levelled — as 
is also the point — which makes dentate scalers of movements 
in lateral directions. It is an instrument that can be intro- 
duced easily into the deepest pyorrhetic pockets without 
mutilating the tissues. The shanks are so shaped as to fol- 
low the contour of the roots, thus interfering least with the 
working point and one's tactile sense. 

"It is very essential to keep all instruments, and particu- 
larly these, in perfect condition as to sharpness. Drawing 
it across an Arkansas stone may at times seem not to accom- 
plish the sharpening of this instrument. Upon examination 
with a magnifying glass, it will be found that one of the 
serrations has worn away. It is necessary to grind with a 
very fine stone until the apex of the next serration is reached, 
when the full efficiency of the instrument will be restored. 

"The other very vital phase in the treatment of pyorrhea 
is the maintenance of a degree of cleanliness of the teeth. 
This is practically impossible in many cases, especially where 
the interdental septum of alveolus has been destroyed, leav- 
ing recesses between the teeth or bifurcations of the roots, 
which can not be protected from recurrent plaque forma- 
tions freighted with micro-organisms or from food particles 
which must decompose and contribute an irritating factor. 
The physical resistance of some patients treated for pyor- 
rhea is so high and their facility at oral hygiene so proficient 
that very little effort suffices to maintain a healthy condition, 
but there are many others who try our patience and resource- 



368 Practical Pyorrhea Alveolaris. 

fulness thoroughly. No doubt, everyone laboring in this 
field has felt disheartened at times to find that inflammation 
would persist in some cases in spite of all approved practices 
and that, although the pyorrhea — pus symptoms — had been 
cured, there would be periods of acute inflammation at given 
sites, increasing mobility of a tooth or teeth and finally re- 
sulting in the loss of same. 

"To me, the persistency of gingival irritations due to mu- 
coid adhesions, not necessarily in deep pockets but in irregu- 
lar areas or under the shelves of tipped teeth, etc., stimulated 
my investigations. The metallic salts (silver, zinc, copper, 
etc.) in solutions were tried, but their effects were very tem- 
porary. The bifurcations of roots were filled with gutta 
percha amalgam or the oxy-phosphate cements, but they 
all had their disadvantages. The problem for bifurcations 
was solved when Dr. Ames' copper phosphate cement was 
given to us. It was quite a while after using it for bifurca- 
tions before I had the courage to use it interdentally, espe- 
cially where the pockets were deep; but now it is part of my 
treatment of any given case to use copper phosphate, the 
"original" preferably, to fill the interdental spaces com- 
pletely, overlaying it wherever it shows when the teeth are 
exposed with a hydraulicphosphate pigmented to make it 
less conspicuous. Many teeth become susceptible to ther- 
mal shock after the roots have been operated on or are 
hypersensitive to brushing. Cover with copper phosphate. 

"My procedure is first to allow some days to elapse after 
operating to permit such granulations to occur as will and, 
too, to determine the recession of pyogenic conditions. Then, 
after determining to which tooth-wall, the mesial or the 
distal, to make the cement adhere, the tooth is protected 
with cotton rolls; the space freed from moisture by absorb- 
ents, not dessicated; the cement is mixed with plastic, carried 
to place and then forced to the deepest recesses with a piece 
of spunk; more copper phosphate is applied; the spunk used 



Dr. LeRoy's Treatment. 369 

again until the cement protrudes on the opposite side of the 
space, then it is shaped about the tooth, covered with a piece 
of tin foil for a few minutes until hardening has taken place. 
The tin foil is removed, the edges trimmed (be particularly 
careful .not to allow jagged edges to irritate the gums or 
cheeks), and the operation is complete. 

"Of course, the color is against copper phosphate, but 
nothing else that we have at the present time will do what 
it does. It is positively germicidal and antiseptic. Some 
find it difficult and messy to use, but the results obtained far 
outbalance the disadvantages. It sticks to anything and 
everything, and almost everlastingly. Once in awhile it will 
break away, but — replace it. 

"I have used it in this way probably ten years and would 
not keep house without it. This is the first time that I have 
published these findings, but I am so sure of the great effi- 
ciency of sealing interdental spaces completely that I am 
glad of the opportunity of contributing to your interesting 
book something that has revolutionized pyorrhetic practice 
for me and given me a greater latitude of success." 



CHAPTER XXIX. 
TREATMENT. 

TREATMENT. DRUGS COMMONLY USED. — APPLICATIONS 

USED BY YOUNGER, MEISBURGER AND HEAD. 

If there is one general criticism that can be made against 
the dental profession it is in regard to the general method 
of dealing with patients presenting themselves with cases of 
pyorrhea. It has been the experience of all of us who have 
treated a considerable number of such cases to see patients 
with merely a condition of slight irritation of the gum mar- 
gins who had been informed by some dentists that their 
case was incurable. We find that dentists, as a general rule, 
do not like to treat these cases,* preferring to throw them 
oft with the simple statement that the case is incurable. 
This certainly lessens the respect of the patients for the den- 
tal profession, but of much greater importance is the fact 
that it means the loss of many teeth which should be saved; 
the patient, believing absolutely in the integrity of the den- 
itst, has gone on and on without seeking other aid. 

If a splinter should stick in the finger the tissue soon turns 
red and suppuration takes place. Now, exactly the same 
thing takes place in the mouth. If a dentist should stick a 
splinter in his hand, he probably would not inject any of the 
strong pyorrhea remedies. Rather he would remove the 
cause. The same thing is true in pyorrhea. The pathol- 
ogy of the tissue surrounding the splinter is the same as that 
which makes the red tinge on the gums and the final sup- 
puration. The pathological picture is simple and plain; 
Dr. Tolbot goes so far as to say that the dentist, allowing 
a patient affected with disease to go out of his office without 



Treatment. 371 

telling him of his condition, is guilty of mal-practice. Incip- 
ient pyorrhea is easily cured. Just as removing the splin- 
ter cures the finger, so incipient pyorrhea will get well in a 
few days if the teeth are cleansed and the tartar removed 
from under the gum margin. 

Every dentist should know the facts now so well estab- 
lished regarding the beginning of this disease; no matter 
what the condition, a great deal can be accomplished by 
treatment that is simple and easy, giving the patient great 
relief and saving teeth for future service. 

Of course, it must be realized that hard work will often 
not be paid for at the fees we are accustomed to receive 
for other work; but if we do our duty towards this end, 
we will soon become more expert and in time our success 
will enable us to receive reasonable compensation. 

Dr. D. D. Smith says: "Pyorrhea alveolaris is by no 
means a subject to be treated in a hit or miss haphazard 
manner; it is a foe worthy of the steel of a valiant aggres- 
sor and consequently requires careful consideration, a steady 
hand, a keen sense of touch, and sound judgment." 

Dr. Louis Meisburger writes: "I would like to say that 
the thing uppermost in my mind at present and which, unless 
persisted in by the author and teacher will ultimately bring 
into disrepute the honest efforts of those who are giving 
their best endeavores in the treatment of pyorrhea, is that 
dentists are not, as a rule, willing to devote as much time to 
acquire the skill necessary to obtain results in pyorrhea as 
they do to any other branch of our work. Until this is 
done, they can not appreciate that surgical interference, 
above all else, is of paramount importance in accomplishing 
results. To this end they must acquire not only the deli- 
cacy of manipulation in instrumentation, but also must 
familiarize themselves with the anatomy and dental histology 
in the field of operation to do the work intelligently." 



372 Practical Pyorrhea Alveolaris. 

Dr. M. M. Bettman says: "The main point in the treat- 
ment of pyorrhea is the thorough scaling and polishing of 
the roots and the correction of any malocclusion which may 
exist, no matter how slight." 

Dr. R. G. Hutchinson, Jr., says: "The time will never 
come when every dentist can successfully treat pyorrhea. It 
is unreasonable to expect that what requires special training 
can be accomplished by one who only occasionally engages 
in such practice. It is also unreasonable to believe that be- 
cause the operation can not be accomplished by the majority 
it is impossible." 

The Younger method, as carried out by Good and others 
of this school, consists of first thoroughly removing all con- 
cretions and carious bone, then injecting pure warm lactic 
acid into these cleansed pockets, with care that it does not 
run over the external gum margin. This is effected by the 
use of a small caliber, round pointed steel needle on a hypo- 
dermic syringe. The particular one used by Good, can be 
procured from Sharp & Smith, of Chicago. This treat- 
ment is repeated three or four times at intervals of several 
days and only a few teeth are treated at a sitting. The ob- 
ject of this treatment, as claimed by these operators is, that 
the acid produces somewhat of a solvent effect upon what- 
ever concretions have remained and also upon the carious 
bone. In addition to this, it has a somewhat stimulating 
effect on the granulation tissue which surrounds the tooth 
roots and a new attachment is formed. While it is un- 
doubtedly true that this treatment has produced good results 
it is just as true that their method can not be said to be 
without objection. I believe the success they obtain can 
be attributed more to the thorough cleansing of the pocket 
than to the injection of this acid. 

I am led to believe that the same result could be obtained 
by the injection of almost any other strong drug such, for 
instance, as Tartar Solvent, which, it is said, does not have 



Treatment. 373 

the disadvantage of dissolving the tooth root. If you will 
place a tooth root in pure lactic acid and allow it to remain 
for twenty-four hours, it becomes changed into a jelly-like 
mass. This is prevented in the mouth by the fact that the 
injection remains only a minute before it is washed out by 
the surrounding liquids, but there is the possibility that some 
of it may be retained in a remote cavity. 

One of the most perplexing cases that I have had to diag- 
nose was that of an army officer who had been treated by 
the lactic acid method. He had received great benefit from 
the treatment, but from time to time he suffered excruciating 
pain on the side which had been treated. Several examina- 
tions, at intervals, were made in an endeavor to diagnose 
the cause of this trouble, but without success until an X-ray 
was made that showed a cavity in the upper cuspid root about 
the middle third. The instrument was inserted through the 
old pocket opening and, when high enough, fell into this 
cavity. The patient almost leaped out of the chair with 
pain. There was nothing that could be done except to ex- 
tract the tooth. It was found that the constant application 
of this acid had dissolved the tooth with the final result of 
exposure of the pulp. There was no sign of decay except 
such as acid produces on tooth substance. While this is 
probably a rare termination of the treatment, at the same 
time, it is well to call attention to the possibility of this com- 
plication occuring in deep pockets. Another objection to 
the filling of these pockets with this or any other strong 
drug, is the great amount of pain which sometimes accom- 
panies such treatment. It is well, if possible, to secure some 
degree of anesthesia of these sensitive teeth before subject- 
ing them to the pain of this treatment. 

Another drug used by many is trichloracetic acid. After 
thorough instrumentation, sections of the gum are dried with 
cotton rolls or napkins and the pockets are saturated with 
a ten per cent, solution of trichloracetic acid, using small 



374 Practical Pyorrhea Alveolaris. 

ropes of cotton, or wood tooth picks. This treatment is re- 
peated in three or four days but should not be used more 
than three applications. 

After the operation of curetting out these pockets, if sup- 
puration continues, Dr. Kelsey recommends the use of phe- 
nol-sulphonic acid to be applied with a small pointed wood 
applicator. 

Deliquessed chloride of zinc, very slightly diluted, and 
applied on small wood applicators into pockets, has some 
advocates. 

Fielder, of the Royal University of Breslau, modifies the 
Younger treatment as follows: "After scraping away de- 
posits, the teeth, including their necks, are polished and when 
they have been dried we introduce iodine or lactic acid with 
iodine tincture because the former is borne badly on account 
of its nasty taste, and also because in some cases it produces 
severe pain. I introduce both drugs into the pockets on 
Japanese bibulous paper wound around nerve needle. Often 
from two to four medical after-treatments suffice, carried 
out once or twice a week." 

The result obtained by the use of these drugs is the cica- 
trization of the tissue. 

Dr. Louis Meisburger reports excellent results from the 
use of a two or three per cent, solution of iodine to flush 
the pockets after operation. The making of this solution 
he expresses in a rather characteristic manner: "This can be 
approximated by getting the color of light beer. In this 
connection I might say that to those not familiar with beer, 
the ginger-ale color answers as well." 

Several years ago, Dr. Joseph Head, of Philadelphia, 
gave a most sensational report, claiming that bifluoride of 
ammonia has a most peculiar action of dissolving tartar from 
the teeth without harming the tooth structure. As teeth 
and tartar are the same chemically, this seemed most re- 
markable. This preparation has a place in the treatment 



Treatment. 375 

of pyorrhea and we quote at length from his own descrip- 
tion of this method. One precaution that must be ob- 
served is to secure a suitable syringe, preferably the celluloid 
syringe. This holds a small quantity and will deliver drop 
by drop. Dr. Head thus describes his method: 





Fig. 104. Celluloid Syringe with Platinum Point. 

No flooding of the mouth. One or two drops at the bottom of the 
pocket. 

"Through an extensive series of experiments it was 
proven that a twenty to twenty-three per cent, solution of 
bifluoride of ammonia (an acid salt of hydrofluoric acid) 
will disintegrate the tartar on a tooth as readily as hydro- 
fluoric acid itself and also leave the tooth apparently unsoft- 
ened. Later experiments have shown that this solution can 
also be applied to the gums with the most beneficial effects, 
as it seemingly stimulates the tissues and diseased bone to 
such healthy action that deep pockets around loose teeth 
speedily fill up with healthy firm tissue and the sensitive 
teeth are reunited to the gums, becoming secure and useful 
agents in the process of mastication. After one or two in- 
jections, the soreness will largely disappear and all the tar- 
tar scale that could not be so easily and painlessly removed 
at the first two sittings tends to be so loosened that its thor- 
ough removal by the scalers is easy for both patient and 
dentist. After four or five applications, one week apart, 
black scales that have escaped the scaler will sometimes be 
found floating loose in the pocket so that they can be readily 
picked out and the root will be as smooth as velvet to the 
touch of the instrument. 



376 Practical Pyorrhea Alveolaris. 

"In closing, perhaps, it would be well to tersely run over 
the steps of my treatment of pyorrhea. Take off all tartar 
that can easily be removed and cleanse the mouth as thor- 
oughly as can be painlessly accomplished, at the same time 
instructing the patient in the use of brush, floss silk and 
mouth wash, pointing out particularly where he fails to 
reach the bacterial plaques, and demonstrating what motions 
of the brush are necessary to remove the plaques. The 
syringe should then be filled with bifluoride of ammonia and 
the platinum point inserted near to the bottom of the pocket 
or pockets, which should be filled full from the bottom to 
the top. During the operation of injecting the pockets, the 
cheek and tongue may be guarded with napkins with which 
all excess or overflow should be wiped away. Then the 
patient should be allowed to spit for a minute or two when 
the mouth may be slightly rinsed with water to remove any 
excess of acid. Less irritation to the mucous membrane 
occurs from this method than that formerly advocated, 
which consisted in allowing the solution to rest in the pocket 
for a minute or two minutes. The patient is then dismissed 
with the instruction to return in a week. He is also cau- 
tioned to carefully observe all directions on home prophy- 
laxis. When he returns next week the teeth are again 
scaled as far as feasible, cleaning them thoroughly with 
brush and pumice and a coating of tincture of iodine. When 
this is finished another application of the bifluoride is made 
as before. The procedure for the third sitting is as for the 
second, but usually after that the teeth are free from tartar, 
the pockets have started to heal and the treatments need be 
for a period of only about fifteen minutes, just long enough 
for the application of the bifluoride and the little cleaning 
and scaling required. The bifluoride should not.be applied 
oftener than twice a week and usually once a week is more 
desirable. Of course loose teeth should be tied to their 
secure neighbors whenever feasible." 



CHAPTER XXX. 
TREATMENT— CONTINUED. 

TREATMENT OF MERRITT, DUNLOP, LUNDY, WEST AND REID. 

TREATMENT OF MERRITT. 

Report of an Interesting Case of Pyorrhea and the Treat- 
ment Employed. By Dr. A. H. Merritt, New York. 

(Dr. Merritt, at my request, wrote me this description 
of a pyorrhea case in a patient 18 years of age, stating that 
it is the youngest patient in all his experience with so ad- 
vanced a case. The radiographs of this case were made by 
Dr. George M. MacKee. (Fig. 105.) 

"This case I am seeing for the last time on June 21st. 
The gums have already resumed normal color, the discharge 
of pus which was enormous has entirely ceased, the teeth 
are markedly more firm and except for slight sensitiveness 
to thermal shock perfectly comfortable, though the patient 
was in constant pain all about the gums, with a calcic abscess 
on gums over one molar when treatment was commenced 
in April. Treatment to date has been entirely local, except 
the administration of calomel and sodium phosphate for con- 
stipation. The local treatment consisted of a very thorough 
scaling of the root of each tooth with scalers made from my 
own design, finishing in some instances with fine files, with 
these latter the edge of the alveolar plates, and where nec- 
essary smoothing off ragged edges. This was followed each 
time by the application of weak solution of tincture of iodine 
(35 to 50%) with careful prophylactic treatments. 

"All weakened teeth were ground off so as to relieve them 
from undue stress. The patient was carefully instructed 



378 



Practical Pyorrhea Alveolaris. 




Fig. 105. Radiographs of Dr. Merritt's Case. 



in the home care of her teeth, proper brush provided and 
instructions given in its use (two minutes each time, four 
times daily, straight up and down over all the gums). This 
briefly outlines the treatment I follow in all such cases with 
most gratifying results. This particular case was exhibited 
at a public clinic before treatment was begun and will again 
be shown next autumn to the same men to confirm my ex- 
perience in such cases. 



Treatment — Dr. Dunlop. 379 

"To me it seems that there is too much theory in the treat- 
ment of all pyorrhea cases, making it appear to be very 
difficult, when in reality it is comparatively simple." 

TREATMENT OF PYORRHEA WITH ETHYL BORATE 
GAS, BY DR. WM. F. DUNLOP. 

"The Dunlop Treatment consists primarily in the intro- 
duction of oxygen into the tissues and circulation, and stimu- 
lating nerve control. It had long been recognized that 
oxygen could probably cure pyorrhea, and many experiments 
have been made with a view to forcing the gas directly into 
the gums. These attempts failed because pure oxygen un- 
fortunately burns up live tissue as well as dead tissue. 

"I use the ethyl borate gas under pressure, which is intro- 
duced by means of a small needle at the free margin of the 
affected gums. The features of this gas as against pure 
oxygen are : first, that it destroys only dead matter, by stimu- 
lating the circulation. The live tissues are not attacked by 
the gas at all. Secondly, the gas travels through the pus 
passage and ramifications about the roots and along the 
jaw, not by pressure, but by its own natural affinity for pus 
and dead matter. 

"When a case of pyorrhea has been cured and the pas- 
sages have been emptied of microbes and putrifying secre- 
tions, the gums refuse to take the gas. 

"I believe that this gas cures by virtue of its burning up 
dead matter and its stimulation of blood circulation. Re- 
cent experiments suggests that gas gets results as a germi- 
cide by increased circulation. 

"Before applying the gas it is first necessary to remove 
the original cause of the disease, viz. : the local irritation. 

"After the operation is completed we are ready for the 
vapor treatment; the gums are sprayed and all the pockets 
fully impregnated with the antiseptic from the machine. 
Before the patient is discharged, place a strip of the pocket 



380 Practical Pyorrhea Alveolaris. 

packer over the free margins of the gums, pressed firmly in 
between the teeth, both lingual and buccal. This must re- 
main in place in order to keep the tender surfaces of the gum 
free from contact with the secretions of the mouth and any 
other foreign substance. The deeper pockets are to have a 
small portion of the pocket packer forced up into them, and 
a warm instrument passed into it while in position. This 
will hermetically seal the space or pocket. 

"When the patient presents himself for the second sitting, 
the pocket packer is removed, the gums thoroughly sprayed 
with the machine, the same being properly charged to throw 
this spray without the use of the needle. You next put the 
needle on the tube. Opening the valve on the machine it 
will be found that a dry gas or vapor escapes from the 
needle. In passing the needle around the gingival margin, 
or perhaps slightly under it in some cases, it will be seen that 
the gas is taken up by the inflamed ducts, and it will pass up 
through the gums, forming little stringers, and will only stop 
when they seem to reach their destination in the glands them- 
selves. This action is visible to the naked eye. 

"Generally, where this inflammation is pronounced, there 
will be a cyanotic condition of the gums, caused by improper 
elimination, or a lack of oxygen. This gas being carried 
into the tissues is robbed of its oxygen, and the solids are 
precipitated into the tissues, causing an inflammation, which 
brings blood to the parts, the same as any other irritation 
will cause an influx of blood, but with the difference that in 
this case the tissues are thoroughly oxygenated and circula- 
tion is re-established, the cyanotic condition disappearing. 
The tissues producing cells are stimulated to action, and con- 
stantly fed by the application of this gas until they will re- 
ceive no more. If this is kept up at intervals — with a few 
days apart — and the surfaces kept clean, we have not only 
the rebuilding of this lost material, but there is a re-attach- 



Treatment — Dr. Lundy. 381 

ment of the root of the tooth to the alveolar dental mem- 
brane and a consequent cure." 

The above article on the Dunlop method is given for the 
reason that it is entirely a new departure in our methods 
of treating pyorrhea. The author has endeavored to secure 
more data as to its relative efficiency, but it has not been 
on the market long enough to gather any definite informa- 
tion. 

There are many who claim that deep infection in the alveo- 
lar process can be relieved by its use. However, there is 
some opposition developed against it as voiced by the follow- 
ing quotation from Talbot, in his "Interstitial Gingivitis and 
Pyorrhea Alveolaris." 

"Within the past year a machine has been placed upon 
the market for the supposed purpose of forcing oxygen 
through the tissues in the treatment of this disease. I have 
watched this process of treatment 'with fear and trembling' 
since the method of application forces the pus germs through 
the inflamed alveolar process. Why infection does not occur 
is a mystery. This method of applying drugs and forcing 
pus germs into the tissues without infection is a strong point 
in favor of the non-infectious theory of interstitial gin- 
givitis." 

TREATMENT OF DR. E. A. LUNDY. 

"The majority of cases presenting are simply an oral 
manifestation of a systemic disturbance. For twelve years 
past my treatment has been both from a local and systemic 
standpoint, and results obtained have been far more satis- 
factory. 

"My systemic treatment varies in individual cases, but is 
arranged with a view to the establishment of a normal elimi- 
nation and assimilation. I find in the majority of cases that 
constipation is present with resultant auto-intoxication, and 
my treatment is with a view to overcoming such conditions. 
My first efforts may be by internal medication, but later I 
resort to that of a proper dietary, in which I try and pre- 



382 Practical Pyorrhea Alveolaris. 

scribe such foods as are compatible and require chewing. I 
also try and prescribe a non-uric acid dietary. 

"My favorite remedies for local treatment at present are 
Dr. Sens solution of iodin and potassium iodide, one part 
to water four hundred parts, making practically a one per 
cent, solution." 

TREATMENT OF DR. J. B. WEST. 

"The treatment of pyorrhea by me has been a gradual 
evolution from the time when I only removed the calculus, 
or at least tried to, and used some if not all of the astringent 
drugs that were included in my knowledge of Materia 
Medica. 

"The more I have studied the histology of the tissues in- 
volved and the pathology of the disease, the more convinced 
I have become that in the majority of cases people suffering 
from pyorrhea alveolaris have some other pathological sys- 
temic condition acting as a predisposing etiological factor. 

"I do not wish to be misunderstood as advocating that all 
cases of pyorrhea are systemic, nor do I believe from my 
clinical experience that all cases are the results of local irri- 
tation. We must use our common sense and diagnose each 
and every case. 

"In my method of treatment, I made a complete physical 
diagnosis. In doing this, I keep a record on the accompany- 
ing card, giving data of temperature, pulse, blood pressure, 
heart examination, haemoglobin, red and white blood count, 
blood smear, differential count of leucocytes, and a complete 
urinalysis. I also make a smear of pus, examining for mi- 
cro-organisms and endanneba. We now have all the physical 
data on the patient and are able to make a diagnosis. If we 
find the patient suffering from any grave systemic disease, 
we refer him or her to the family physician. In the great 
majority of cases, especially if the patient is leading a seden- 
tary life, we find a history of faulty elimination, acidosis, 
indicanuria, and deficient elimination of urea. (Figs. 106- 

7-8.) 



Treatment — Dr. West. 383 

"This condition we strive to correct by proper systemic 
treatment at the same time we are locally treating the case. 

"Regardless of the enthusiasm of Drs. Barrett, Smith, 
Johns, and Bass relative to the use of emetine hydrochloride 
as the proper treatment of pyorrhea, we think it conclusively 
proven that scientific root surgery offers the only reliable 
treatment of pyorrhea conditions to-day. 

"We approach the disease from the constitutional aspect, 
believing that for every effect there is a cause and that every 
law of medicine enjoins us that, if the cause is not removed, 
we shall continually have a recurrence. 

"A great many of our cases are cases of mouth infection, 
and we have pyorrhea complicated with rheumatoid arthritis, 
endocarditis, myocarditis, lesions of kidney, and various dis- 
eases of the gastro-intestinal tract. In these cases, we inocu- 
late culture media from the deep pyorrhea pockets and have 
an autogenous vaccine prepared, which is used to raise the 
resistance of the patient to the prevailing micro-organisms. 

"In our local treatment, we sterilize the field of operation 
in the mouth as thoroughly as possible, using iodine, then 
curette the pockets and plane the infected surface of the 
cementum. After we have curetted from the pockets all 
gangrenous peridental membrane and necrotic alveolar pro- 
cess and planed the cementum, we have a blood clot filling 
the pocket. This, if we can prevent it from becoming in- 
fected, acts as a matrix for new granulations to fill the 
pocket, healing tight around the tooth root. To prevent the 
ingress into the pocket of food, saliva and debris from the 
mouth, as well as micro-organisms, I have not found anything 
better than the No. 1 and No. 2 AA Pyorrhea Treatments 
of Adair. (The method of preparing these is given in an- 
other chapter.) This preparation, when in contact with the 
saliva, thoroughly seals the pockets for from twenty-four to 
forty-eight hours. The application may be renewed as fre- 
quently as necessary until healing takes place. 



3»4 



Practical Pyorrhea Alveolaris. 



Name /Tfiw ^ Case 

Address raUggZdk^^ZLft Xtoxt-QcfTUf'ti 



A 




ft 




& 

© 


ft 








A 


A. A/ 


VAMJ 


m 


t 






m 


t 
c 


'V 

m 


V 

1*1 




V 
n 


V 


0' 


8 


A 


V 
A 




1/ 

il 


V 


V 


v V \ 

i 1/ 


1 


fcj 


W 


w 





a 


tr 


"H 


#y? 


w 


Gingvitis 






F 






Jr. 

y 


.Yi 

y~ 




y. y j 


r.v. ... 


y 




r 


K 


/^ 


y 
































k 








D 








y 


f 


k 


V 


K i^ 






Kecession 










c 


K 


y 


/^ 


^_kl 
































f 







































































rk 






















Deposits-hard ■ 






^ 


V 


► 


J-- 


y 


k 


\^ y i 


^ > C |/ 












4 










J 


otain 




















1 










































































































K 


K 


\/ 


^ 


v V 




















































































a 


a 










G 


G 




























i • 






















is 


Malocclusion * ( 


t 




















y 




























y 


K 


^ 


k 


^ 


i^ 


v 


^ 


y y i 


^ k- 


It 


TeetA J* est 


















i . 


.L..5T 




V 


*- 














1. 1 


* 


!*" i 



Fig. 106. The Examination and History Card for Pyorrhea Cases as 
Used by Dr. J. B. West. 



Treatment — Dr. West. 385 



HISTORY 

Sex \ /U*HftM-r.k%<t . 3./T .. . . . .Occupation.'?^ E ^ i ^^^- 

Married or single /%4A*t4s/. .. • // 

Local Condition ^-^ j, t / ' j/ — 

Soft tews.ttJ^.fp*^.^ ."^.^ 

Saliva.-/. . k s7-*-.6 OyTWA f. 



1 \ 



Tendency to Caries ;. SDi&AVWU&.jf&C*. 

Wearing . . /(0 Erosion 

General Conditions t 

Diet. . OMt/ife '.jf.f&4. ,__ .Afatt 






Habits. A** fd^^T. M^^fff.f9f^jf. . M~. 

^^P^h^4h^J % / 

Hereditary factors. . . ^^/^?r 



General hea!th7^*r\^r.ty**...'Pain in joints 4fr?ty .&£tf . <**+?• 

Muscles Jk ^^^^/^^Headache. //p *.. 

Rheumatism CA*r^ (&$**& . Asthma. . &. 

Constipation /h^S Kidney Disease. /Y* , 

Liver or venereal disorders \M^> fp-W d.A<f*ff'&&*. ***?*> - 

Tuberculosis. . //.0 Stomach disorders. . . r/P. 

Nervous lesion . . . f/p 

URINALYSIS .(ff.t^. fc. ./.#. Amt. in 24 hours <fU?*^<* . ^rfc^ 
Sp. Gr /. Q/K . Color d*?*^. . Transparency. '.£****«% .... 

Reaction .(Af*tff.\ . » .... Degree of Acidity. . 9?M , 

I ndican ./$»«•. Sugar ./%&&■ Albumen . 4fc***T?, . . . 

Urea, $A/f? Uric Acid ./ft Blood . .— TT. . . Pus. : 

Gas. int. tract 

Remarks (fa**/**********^ \ tv-csi*t *t#.*6- #4 /tT*&. " 
"//J/"*- <&**<f /*WIA la+tsis Ac4.4/ J*r-t 4/t4(/i**tS~'S<rt^ 

Fig. 107. Back of Figure 106. 



386 Practical Pyorrhea Alveolaris. 



HISTORY AND PHYSICAL DIAGNOSIS 

Temperature before treatment. ...7.7.. . . .rMiddle. 7.0.^r. After 
Pulse before treatment... !/.& Middle. ..#.0.. After 



BloodPressure Determinations f'J^"* Q> • Oo 

Part examined£fc^-/T. f****<r . . . Posture.-<S/<r*r.-^^' . Pulse rate.^.^- . /. .«/*?. . 

Before treatment Middle f. After 

Systolic. /.CO. mm Hg jf.xT. mm Hg mm Hg 

Diastolic ...d>.A... , "... <?3? " " 

Pulse Pressure. . . ■s'.^v. "...'. *S.3. 



Pressure. . f . . jf.VT. . M " . . /.fC. " ,- " __^ 

M^%/fj.J%#,.£./£ mmJ8,s*EMrj£.7?'a 



Mean Pressure. 
Date. 
Ausculatioiuof Heart 

Mitral area.^.<H*^//^Sf*^ulmonic area. . ttf&t&f^Tr^ ■ 
Aortic area. jy^^^.^TT^, Tricuspid area. 

Remarks 

ExanaJnation of the Blood T**?-" T^V 

Haemoglobin. Before treatment /.^.. . Middle. .f..„. x .... 

Stained B lood Film. . . . typ*J ■ Stain 1&A*> 

(a) Red Corpuscles 



.!£!:::.... 

Poikilocy tosis. . . . /£.0. . . . . Stippling. 4(/> .^ 

(to) Differential Count of Leucocytes '/+4T f*^"*- *** />•*• C 

Polymorphonuclear Neutrophils in 1 c. mm.., 

Lymphocytes in 1 c. mm Eosinophiles in 1 c. mm , 

Transitional Forms. In 1 c. mm. Basophiles. in 1 c. m in 

Turks Irritation Forms, in 1 c. m m 

No. of Red Corpuscles. Before treatraent.C^4#&Iiddle.'#^£^^After 

No. of Leucocytes. Before treatmcnt.Zr P.P.. . . Midd!eiT<^. (>..... After 

Second Urinalysis. Date. . /J#TJ.> 9.j. . /.f/.4f.. .... 

Amt. in 24 hrs Sp. Gr. f.\ P.** $. . Cclor^T? .™". Odor,^**. . . . 

Transparancy£A?fw.Pveaction.^£<W.... Degree of Acidity. 3 P.. .Indican><^» 

***** 'Aootnuf ~ Rn.rnr /^^*<-^ TTroA<2»^>^" 



Albumen . .$.f?**r. . /Acetone. 7. Sugar. . .<K&**rr\ . . . Urea. 4k/f* 

Uric Acid. l4*+S.. .Blood. . ^T^. Tus. , 7T 

£££&. or ^a^X^.^/^^y^-G-" 

Smear M4 Stain.- ~: Culture. yfc&?- Autogenous Vaccine. M&&S.. . 

Firetdose, No. of Bacteria.fj fc*y£#/:?.$*5..#*/^ 

Last dose, No. of Bacteria. /, $.9.?,?.°.?i?. d .(>.... Date.*^*^ £9/* ~~ 

How oflcn ffiven.and No. of doag4rf?&/2?f&. *.&&T... z.. ...... 

Diagnosis. <&*$U/U, . X^tp*^**"^. #(u. 4) $ff m frffi??*f.. 
Prognosis . ..&#**?. . £HG**f.. $. . *#£p. /^^v^rrf. .^*r*?**^?. 

Fig. 108. Physical diagnosis sheet of Dr. West. When made out is 
pasted by edge to card as shown in figure 106. 



Treatment — Dr. Reed. 387 

"If we can prevent pressure and infection, according to 
the research of Macewin of Glasgow new bone will be 
thrown out by the osteoblasts at the margin of the freshened 
alveolar process and the tooth will be much firmer in its 
socket. 

"We realize that this doctrine is revolutionary, but Hart- 
zell, Logan and Fletcher, as well as the author, have noted 
it as a clinical fact. 

"After the local surgery has been finished on the various 
teeth, we have found that it is necessary to keep the teeth 
perfectly clean and the surfaces polished by oral prophylaxis, 
as advocated by D. D. Smith. The granulations filling the 
pocket are, like any other scar tissue, tender and unable to 
withstand the abrasive action of foods during the process 
of mastication and must be stimulated by massage and con- 
tracted tight around the tooth. We use an alcoholic solu- 
tion of the sulphocarbolate of zinc applied by means of cot- 
ton rolls, as advocated by Skinner, or Talbot's massage 
brush. This wash with massage is applied to the gums twice 
a day after the pockets have healed. 

"We check up the physical condition of the patient at the 
middle of the treatment and at the close, as shown on the 
history card. By this means, we have the complete data of 
the patient before treatment and at the close and can show 
him the actual improvements in his case." (Figs. 106-7-8.) 

THE TREATMENT OF PYORRHEA ALVEOLARIS WITH 
SUCCINIMIDE OF MERCURY, BY DR. G. H. REED. 

The latest claim for victory over pyorrhea comes from 
Dr. G. H. Reed, of U. S. Navy. He reports in "Items of 
Interest" for April, 19 15, several cases treated by deep in- 
jections of succinimide of mercury into the muscles of the 
buttock. The first injection was seven-fifths grain. This 
was followed by an injection of one grain after an interval 



388 Practical Pyorrhea Alveolaris. 

of three days, and by three-fifths grain three days later. 
The claims set forth for success of this method is that the 
mercury is an amoebacide, germicide and produces a hyper- 
aenia and tonic effect in the gums. The author has not had 
the opportunity to experiment with this remedy, but the suc- 
cess of this method for the treatment of tubercular cases and 
other parasitic diseases leads us to look forward to further 
experiments and reports. 



CHAPTER XXXI. 

THE AUTHOR'S METHOD AND SYSTEM OF 
TREATING PYORRHEA. 

For the first time the author is afforded the proper oppor- 
tunity of giving in full detail each step in a systematized 
method of treatment which has for many years proved highly 
efficient in his practice. 

While many papers have been read and published and 
clinics given, only parts of his work could be presented. For 
this reason many of these contributions were not thoroughly 
understood nor were the methods generally adopted; but 
the author has the satisfaction of knowing that some den- 
tists who have visited his office and seen his methods in 
practice have adopted them successfully. 

The author's treatment, having proved so successful in 
his own hands, it is herewith given in full detail with the 
hope that it may prove equally useful to others. 

In the description of this treatment we will consider that 
we have a case of pyorrhea where the teeth are loose, the 
gums swollen, and the pockets are of medium depth contain- 
ing some cheesy disintegrated alveolus; in other words, a 
typical case of pyorrhea. 

Several days before the surgical work the patient is given 
several sittings, at which time the mouth is sprayed out with 
some antiseptic solution or AA Dental Mouth Wash. 

Each time the mouth is mopped out with a "Kuoris," the 
cotton having been dipped in a weak solution of hydrogen 
peroxide and then applied to the gum surfaces. A coating 
of Skinner's Disclosing Solution (formula given page 176) 
is next applied; other good antiseptic solutions for this pre- 
liminary treatment are: 



390 



Practical Pyorrhea Alveolaris. 



ORAL PYORRHEA CHART 




\JJMJSmgL 

^bM&toJfato^.. 

^.j/tir/tf.. 

EXAMINATION 1. No. of teeth involvedlC-T_y._ *K ~.<f..r.... .V*K /T . .'"" 2. No. of teeth with deposits 

on enamel and no destruction of peridental fibres---/- .4?... .*< 3. Teeth with pus discharge-*-*?- ~Y. **'.??- 

4 Teeth loose with nopus discharge - 5. Condition of teeth jff.ft^Kfi.'.... . 

mucus membran-.iWr bo»./fefi^>M?£.__eh.r.Cr of depositsife^^^^^^ 

Occlus,on fiSt:. Prothes.s womfe/^^ JdA^LjS^. /&>&>. ..... 

HISTORY 6. Age-73jTT— ... 7. Duration/*^/*? A Beginning point of inflammatiorrf*r?#?/'-/^^&7 

9 Most recent point of inflammation ...if". 10 Habit* 44 

Oral H^fefJ^tiU.4^i 

11. Parents teeth. $ &C4i&.-C$tT- . lJ££(4 -t&U 

SYSTEMIC CONDITION YJty.M^&$1*-~j£%&d£6£44. ....... Blood pressure- >#*?. 

Urinalysis ■ 



ty.fa.Mm. 




u\\v*...J&u*A. 



##. 



— 12. Have you had any trouble with your digestii 

13 Have you had any pain is your abdomen? /Iff. 14 Which did you notice first — trouble in mouth 

or stomach V-- JjLVU/MJ*. ? 15. Have you had any heart-burn ?...Jt^^~'.. 16. Do you notice 

it- / 

any excess of saliva after eating? -/*■« -■-- 17. Have you any tendency to Diarrhea or Constipation ? 

-Do you use laxatives ?. ^Ky. 18. Do you have Tonsillitis 7.. .^4KK. 

Rheumatism ?--. J »T#Vf. Gont?— -./££. 



Gout 
For what other diseases have you been treated ?. 
Are you under care of physician at present time 
PROGNOSIS 21. Good-./-.VL-J*r7- 



Shortness of breath or palpitation on exertion? 

, fa 




Fig. 109. A simple record chart as used by the author. The pockets, 
amputations and bridgework are marked in the cut of teeth at top of 
sheet. These are put in a loose-leaf binder. 



DR. MEDALIA S MILD 


ANTISEPTIC 


SOLUTION. 




Compound solution 


of iodine 


(U. S. P.) 




Glycerine 


aa drs. s s 


Distilled water 


grs. ii 



The Author's Method of Treatment. 391 

dr. Buckley's pyorrhea 
astringent 

Potassium iodide 

Zinc phenol sulphonate aa grs. 60 

Iodine grs. 80 

Water m 192 

Glycerine grs. 100 

The most important instrument for application of any 
medicant into a pyorrhea pocket is made by mounting a small 
size quill tooth pick on an orange-wood stick for a handle. 
Those who have seen the author use this quill applicator, 
have expressed wonder at its efficiency to deliver a proper 
dosage of medicine to the bottom of a pyorrhea pocket. It 
works just as the point of a writing pen. Dip the quill into 
the medicant, carefully insert to the very bottom of pocket 
and then manipulate the handle just as in the use of a writ- 
ing pen. This will "write" your medicant to the bottom of 
the pocket. The Miller pen is somewhat on this order, but 
does not possess the advantage of a quill in its narrow width 
and length of point. The quill is not affected by any of the 
medicants used in treatment and has the advantage that it 
enables the operator to use agents which no syringe will 
stand or deliver. With all the other means I have em- 
ployed, the liquid "came back" and with this applicator it 
"stays put." 

This preliminary treatment has the advantage of getting 
acquainted with the patients, gaining their confidence, and 
getting rid of any bad odor. By staining the debris around 
the tooth it is more easily removed. 

Dentists differ considerably on the question of extensive 
surgical procedure at one sitting. The general practitioner 
can not give so much time to one patient, and it is advisable 
in this case to take only a few teeth at each sitting. Dr. 
Hartzell takes only a few teeth at each sitting for an en- 
tirely different reason. In his work he has seen some evil 



392 Practical Pyorrhea Alveolaris. 

results following extensive work, such as chills or rise of 
temperature. He further believes that pneumonia, joint in- 
fection, or acute nephritis might result from opening up 
large areas of this granulating tissue which might introduce 
bacteria into the circulation. 

These grave dangers are more than a possibility if the 
operation is undertaken in the ordinary manner, but the 
technique as used by the author, has not only prevented such 
complications, but gives better results from completing one 
jaw at least at each sitting. 

This is due, of course, to the preliminary treatment which 
destroys most of the bacteria and parasites, also to the thor- 
ough irrigation previous to the operation, and the further 
fact that each instrument introduced into the pocket carries 
with it an appreciable amount of cyanide of mercury solu- 
tion, which gives very little chance for live germs to exert 
their action in the circulation. This technique has been car- 
ried out in a large number of cases without a single complica- 
tion, and most of these have been all finished at one sitting. 

This is to the advantage of both the patient and the oper- 
ator, because all the instruments and solutions are made spec- 
ially for each case (just as in a hospital case) and to do this 
all over a half dozen times does not gain anything for either 
party. However, the greatest reason we endeavor to finish 
all of the operation at one sitting is that it is the logical thing 
to do, for in this manner we eliminate all chances of a rein- 
fection into an operated-on pocket from another one which 
has not been treated. Partial surgical operators are rare 
occurences. They can be made so by the dentist with equally 
as good results as to the surgeon. 

On the hour of appointment for the operation the room 
and instruments are prepared just as for any other surgical 
operation. All the instruments needed for the operation 
are thoroughly cleaned and sterilized, the instrument table 



The Author's Method of Treatment. 393 

is wiped off with alcohol and a sterile napkin is placed on 
the table, upon which are laid all of the instruments. 

The point of beginning the operation having been selected 
— generally the right side of the upper teeth — this section 
of the gums is dried off with cotton or bibulous paper and 
either a solution of 5 per cent cocaine is applied or, better 
still, a fresh solution of Novocaine. Dr. Julian Smith, of 
Austin, Texas, has called our attention to the mistake many 
operators make in using solutions containing adrenalin. We 
have a congestion of these end organs, an area loaded with 
foreign material, germs, and parasites which a free flow of 
blood greatly benefits, and the use of adrenalin in any form 
defeats this action. 

Cocaine gives the best results for injecting into pockets 
with a blunt needle. If cocaine has any proto-plasmic 
poison action, it can not exert it here because of the poor cir- 
culation when it is placed and the irrigating process of the 
blood during the operation. 

The infiltration method and conductive anesthesia, using 
novocaine, are most useful when one portion of the jaw only 
is affected, or where only one section at a time is operated on. 
The anesthetic is also inserted into the pocket with a clean 
hypodermic syringe, using for the purpose a long steel point. 
Do not use a sharp needle. The Sharp and Smith needle is 
most useful, the point is small and not expensive and better 
than anything I have found or had suggested to me for gen- 
eral use. (Fig. 1 10.) 

Five or six teeth having been anesthetized, we are now 
ready for the surgical work. Great care must be exercised 
that the gingival margin be not injured for at this border 
there seems to be a fibre which acts like the draw strings 
on a tobacco sack and when once severed, it is never re- 
united. It is a good plan to pack small shreds of cotton 
saturated with the anesthetic into the spaces between the 



394 Practical Pyorrhea Alveolaris. 

teeth, keeping the portion free from saliva for a few mo- 
ments until completed anesthesia is obtained. Generally the 
beginning of pyorrhea at the gingival border is more pain- 
ful than the deep pockets so this method is most important 
to use. 




Fig. 110. A Small, Inexpensive Steel Point Essential in Pyorrhea 

Work. 



We endeavor to use the instruments so as to give the mini- 
mum amount of pain. However, it sometimes happens that 
the very case in which we expect the least pain, is the most 
sensitive. The patient's fears are allayed when they see 
the operator is taking steps to prevent pain. 

As the manner of using the various instruments is de- 
scribed elsewhere, this part of the work is omitted from this 
chapter. The author believes that proper instrumentation 
is the only solution for the cure of pyorrhea. 

In a systematic way begin at the gingival opening of pocket 
and gradually proceed towards the apex of the tooth until 
the sense of touch tells us that the instrument has removed 
all deposit and dead membrane and reached the extreme 
depth of the pocket. (Fig. in.) 

While each instrument is in the hands of the operator, 
he should operate on just as much surface of the tooth or 
teeth as possible, that is, he should go as far as he can be- 
fore another instrument is taken up. 

When through with an instrument or before placing it in 
a new location or pocket it is dipped in a glass having an 
inch of its depth filled with smallest size shot covered with 
antiseptic solution. By dipping instruments into this glass 
we not only disinfect the point but the shot effectually cleans 
the edge from any adhering matter or blood clot. 



The Author's Method of Treatment. 395 

This suggestion, if put into practice by the reader, will be 
worth the price of this book. Just an ordinary heavy drink- 
ing glass is mounted in a frame, and conveniently placed so 
that the operator can reach it without moving his position at 
the chair. The shot can be covered with a 10 per cent. 
Lysol solution (objectionable on account of its odor) or, 
preferably, a 1-500 cyanide of mercury solution. Before an 
instrument is put into the pocket, it is plunged through the 
shot, given a twist, and it comes out clean, and with just 
enough of the antiseptic solution clinging to its point to act 
as a real germicide in the pocket. 

At the end of the operation, all instruments used should 
have accumulated in this glass. This method of handling 
the instruments effectually sterilizes them. They are then 
washed or boiled, dried, oiled and put away in a formalde- 
hyde sterilizer ready for next operation. To clean the sur- 
face of mirrors and pliers during any dental operation, this 
little suggestion will prove most valuable. 

Each selected section is taken up and finished before scal- 
ing other teeth. A section as spoken of means from three 
to four teeth. 

The "root planing" having been completed, I take the 
proper Smith's files and smooth off all roughness which may 
remain or possible grooves cut in the teeth. With Adair's 
small bone curette the disintegrated bone and sharp edges of 
the alveolus are most carefully removed, its point, having 
a rounded end, will not remove sound tissue. Any carious 
bone or sharp corners of alveolus would retard the healing 
of tissue over it. A delicate sense of touch and experience 
is imperative in using a curette in pyorrhea work. 

Scaling of teeth has been practiced since dentistry was a 
profession, but few have achieved that degree of skill which 
could by the sense of touch remove all the dead peridental 
membrane and this porous coat from the dense surface of 
the cementum. 



39^ 



Practical Pyorrhea Alveolaris. 







'8= 






Fig. 111. 



Instruments should as nearly as possible be selected which 
will work in effect like a straight instrument. This relieves 
the muscular tension and aids our tactile sense. We are 
thus in better condition to tell by the feel of instrument what 
we are cutting. 

If the pocket be a recent opening, the peridental mem- 
brane will not have become hardened, and our instrument 
will convey a fleshy sensation. If tartar is encountered, a 
gritty feeling is apparent. When the proper degree of scal- 
ing has been attained, the root surface gives the sensation 
of trying a new blade or scaler on the handle of a tooth 
brush. 



The Author's Method of Treatment. 397 

Carious bone feels much like tartar. Very gently cor- 
rect such surfaces until the feeling gives a harder and smooth 
surface. 

One of the greatest aids for thorough work is the use 
of a good compressed air syringe, such as that made by the 
A. C. Clark Co. However any of the syringes applied with 
switch-boards would answer. This one is the least in the 
way. 

A stream of warm compressed air at from twenty-five to 
forty pounds is directed into the pocket and if the latter con- 
tains any foreign material, calculus or serumal tartar, it can 
generally be seen. This syringe can be handled by the op- 
erator but it saves time to have the assistant trained to do it. 




"\ 



Fig. 112. The Clark Air Syringe, Which the Author Finds the 
Best for His Work. 

In working on the lower jaw, it is advisable to have the 
saliva ejector in place, using the compressed air syringe in 
the manner above described. The air distends the gum 
from the tooth so that with the mirror, the operator can 
see and remove the smaller deposits which, when dry, show 
up so much better than when in a moist condition. 

When cleaning teeth or removing tartar, place the electric 
mouth light on one side of the alveolus opposite the root of 
tooth to be cleaned; you will be able to locate the tartar on 
the opposite side and by reversing the light from side to side, 
enables the operator to find tartar deposits even if they ex- 
tend almost to the apex of the roots. 

Having satisfied myself that the teeth are surgically clean 
and that the disintegrated bone and sharp edges of the alveo- 
lus are rounded off so that the soft tissue or gum can festoon 
itself over the surface without any irritation from projecting 
bone, the entire surface operated upon is then washed out 



398 



Practical Pyorrhea Alveolaris. 




Fig. 113. A case of pyorrhea alveolaris, showing an abnormal growth 
of the inter-proximate gum tissue. There is no use trying to treat a case 
like this without excision of these projections. They are often tough as 
gristle and if left serve as doortraps for food and bacteria. Insert a 
needle just above in true mucus membrane and place a minute quantity 
of anesthetic. Almost immediately you can remove them without pain. 
Use a small pair of curved scissors or sharp lancet. Be sure and cut 
high enough to get all the hard tissue the first time. After the first 
cut it is hard to make a smooth surface. These surfaces heal up in a 
remarkably short time. Arrow indicates direction of cut. Always cut 
toward the tooth. 



with a liberal supply of warm water, normal salt solution, 
or, better still, an antiseptic solution. This solution is placed 
in a spray bottle, having for a point the Good needle which 
we advised for use in the hypodermic syringe. Plenty of 
solution should be used; a full spray bottle is not too much 
for each jaw. 

Another apparatus which I use with good results is that 
used by Dr. Conrad Deichmiller, consisting of a Valentine 
irrigator placed near the ceiling and a common bulb syringe 
inserted at the end of tube to get a greater pressure. This 



The Author's Method of Treatment. 



399 



is not only a useful apparatus for the treatment of pyorrhea, 
but in other dental surgery as well, such as washing out the 
antrum, abscesses, etc. A quart of hot normal salt solution 
should be used in this apparatus. (Normal salt solution is 
made by adding one dram of salt to a pint of sterile water.) 
The entire area of the diseased gums is thus systematically 
gone over in turn. Whatever success the author has had 
in the work, he believes it is due to the thoroughness with 
which the surgical technique is carried out. If any scale of 
deposit, any carious bone, or a sharp edge is left, that par- 
ticular place will not heal, and if it shows up before the pa- 
tient is dismissed the pocket is again opened up and this irri- 
tant removed. 




Fig. 114. This picture shows a carious condition of the process around 
a lower molar tooth. The infection has not only followed the tooth root, 
but has extended externally to the periosteum. (Author's collection.) 
This is the case where the beginner in pyorrhea work is often discour- 
aged. He scales the root surface several times and treats with all adver- 
tised remedies; still the tooth is loose, pus exudes and the gum in- 
flamed. This case in practice might have been a curable one. The gum 
tissue should have been opened down to the bone as far as the arrow 
point, laid open with a small periosteal elevator and this diseased bone 
removed with a bur or curette as far as the white line. The gum instead 
of standing away from the tooth would then be able to hug the tooth 
and the prognosis turned into a favorable one. 



400 Practical Pyorrhea Alveolaris. 

Thorough irrigation with plain warm water or normal 
salt solution is used for no other purpose than that it will 
wash out the debris. We do not use any solution which 
would tend to destroy or prevent organization of the clot. 
It would be preferable not to wash out the pockets after 
instrumentation were it not for the fact that loosened scales 
of deposit might remain to become reattached and give fu- 
ture trouble. If nothing stronger than the solution named 
be used for irrigation, we find that we have as good blood 
clot as though the thorough washing had not been done. 

It matters little whether all the teeth are completed at 
one sitting or not, as the field operated upon is sealed from 
infection from the other parts of the mouth. Whatever sec- 
tion is operated upon, must be finished at this time; if this 
is not done, when the patient returns in a day or two for an- 
other hour of surgical work, we will probably have forgot- 
ten just where we left off or whether or not we have finished 
certain teeth. 

In our operative procedure, we will find fillings which 
have a shelf overhanging the entrance to a pyorrhea pocket 
and we are prone to leave this for future consideration. 
However, as we have given this as a causative factor, it 
should be eliminated almost as soon as found. Sometimes 
the quicker way to do this is to remove the filling and put 
in some temporary stopping, waiting until we have finished 
the operation and can knuckle the filling up in the proper 
manner without any overhanging edges; ill fitting crowns 
and bridges should also be promptly removed. 

Sometimes the deposit of tartar is so hard that it is good 
practice to remove it with a bur, placed in the dental engine. 
It is well to first allow the bur to revolve against a stone 
so as to modify its cutting qualities in order that it will not 
gash into the tooth root itself. The burs with long shanks 
and small heads, as described by Dr. Fletcher, can be used 
to advantage in removing carious bone or cleaning out be- 



The Author's Method of Treatment. 401 

tween the roots of the teeth when it is not practicable to ob- 
tain sufficient force or effectiveness with a hand instrument. 




Fig. 115. This is a case of pyorrhea alveolaris which bled at the 
slightest touch of a brush or instrument. Here it is not advisable to im- 
mediately remove these projectives from the gum as the hemorrhage 
would be great and often lasts for days. Nor is it advisable to attempt 
any instrumentation until the case has undergone a preliminary local 
treatment until the congestion is under control. Dry the gums and 
apply Skinner's Disclosing Solution, Buckley's Pyorrhea Astringent or 
AA Pyorrhea Treatment No. 1 and No. 2. Give the drugs used time 
to run around the tooth, under the gums and time to absorb before 
letting the saliva to the gum. A week of this treatment will make a 
much more satisfactory case for instrumentation and excision of any 
gum tissue. Tough gum tissue as in figure 113 needs no such treat- 
ment, but can be removed immediately. 



I expect the same healing that I would from any fresh 
wound that is filled with a blood clot. I do not mutilate 
the gum at the cervical border. I endeavor to have the op- 
eration practically painless and without any great strain on 
the patient. While our object has been to produce a clean 
wound sometimes after treating for a few days, we will find 
a trace of pus which shows that something has been left in 
the pocket which must be removed. In such an instance it 
will be necessary to again open up the pocket or to inject 
some medicant to overcome the infection which has spread 
into the body of the alveolus. (Fig. 1 14.) 



CHAPTER XXXII. 

THE AUTHOR'S METHOD AND SYSTEM OF 
TREATING PYORRHEA— CONTINUED. 

APPLYING DRESSINGS IN PYORRHEA. METHOD OF MAKING 

NOS. I AND 2 PYORRHEA DRESSING. DIRECTIONS FOR 

POST-OPERATIVE DRESSING. AUTO-INTOXICATION 

IN PYORRHEA. SILVER NITRATE IN 

PYORRHEA TREATMENT. 

APPLYING DRESSINGS IN PYORRHEA. 

Many cases would undoubtedly get well with the surgical 
procedure alone, but no medical treatment known will aid 
these cases unless this surgical procedure has been well done. 
However, in the same patient, with the same degree of op- 
eration on both sides of the jaw, I have tried the experiment 
of using my medical dressing preparation on one side only. 
For the first few days the side not dressed showed inflamma- 
tion, the teeth were elongated, and it was very sore to the 
touch, while the opposite side where the preparation was 
used showed no such symptoms. The reason for this is 
logical. A surgeon who performs an operation, follows it 
by applying a dressing which has a great deal to do with the 
proper healing of the wound. For years the dental profes- 
sion tried and experimented in an effort to get some method 
of covering the operated surface in pyorrhea work. Some 
have tried sponge grafting; some, tying strips of rubber 
dam about the teeth; still others, packing the pocket with 
strong irritating drugs. The difficulty that we have hitherto 
had was that the treatment or medicament could not be kept 
in place. It was immediately washed off by the constantly 



Applying Dressings. 403 

flowing saliva. The failure to use a suitable protection left 
the field of operation a veritable culture tube — the mouth 
containing stagnant saliva, decayed teeth, and many different 
kinds of bacteria. Hitherto, the antiseptics we have used 
have proved failures, for, if strong enough to destroy the 
bacteria, they have destroyed the membrane of the mouth 
or kept it in a raw state. 

Some thirty-five years ago Dr. R. B. Adair discovered 
a peculiar combination of iodine, creosote, tannin and glyc- 
erine which has proved most successful in the treatment of 
pyorrhea. He demonstrated this treatment at the Interna- 
tional Medical Congress in Washington in 1887, giving his 
formula to the profession at that time. 

The combination was difficult to make and it was hardly 
possible to get a druggist to correctly fill a prescription for 
it, hence few dentists adopted it. For this reason we ar- 
ranged to have it made properly under the trade name of 
"AA Pyorrhea Treatment Nos. 1 and 2." The application 
of this preparation under this name was first shown by the 
author in 19 13 at the meeting of the National Dental Asso- 
ciation in Washington. This preparation has played a great 
part in our work and we have by clinic and paper urged a 
general adoption of its use. In the May number (1915). 
of "The Journal of the National Dental Association," in a 
paper on "Pyorrhea and Its Treatment," by Dr. Hartzell, 
page 139, this application received the following endorse- 
ment: "Many substances have been recommended for this 
purpose. The most valuable one of which the writer has 
any knowledge is the following:" Dr. Hartzell then de- 
scribed the above mentioned formula. 

The name Treatment is a misnomer; it should be Dress- 
ing, as it can be used in combination with any other treat- 
ment. Any dentist can make the preparation by following 
the directions described below but will find it a rather 
"mussy" procedure. 



404 Practical Pyorrhea Alveolaris. 

METHOD OF MAKING NOS. 1 AND 2 PYORRHEA DRESS- 
ING.— ORIGINAL FORMULAE OF DR. R. B. ADAIR 

Take one oz. chemically pure iodine crystals. Pour over 
this just enough chemically pure beachwood creosote to cover 
crystals of iodine. Let stand for 48 hours, then stir thor- 
oughly with a glass or wood rod, making a thick mixture. 
When this is settled, pour off from sediment at bottom. This 
liquid is the No. 1 preparation. 

Procure large mouth bottle of about 3 oz. capacity such 
as vaseline comes in. Pack into such a bottle tannic acid 
crystals. Use a wood rod and pack tight, having one-half 
inch space at the top of bottle. Into this space pour glycer- 
ine C. P. — about one-half oz. Let stand for several days. 
If on examination the glycerine seems to have reached the 
bottom, place it on a water bath and leave until the whole 
has become a thick syrup. If glycerine has not reached the 
bottom, add a small quantity of glycerine. After heating 
on water bath, mixture should stand and age for about a 
week. The mixture will become clear and will have the 
consistency of thick molasses. This is the No. 2 prepara- 
tion. 

These preparations are rather hard to make in small 
quantities. They must be just the proper consistency which 
is best obtained by aging. The preparation as manufac- 
tured stands several months before bottling. 

Simple cases will need only three or four applications; 
the severity of the condition and the extent of the operation 
determine the number of applications necessary. This 
"dressing" does not stain a clean tooth — really bleaches it — 
but it does stain every bit of foreign matter on the tooth 
root. I have found it a good idea to use a few applications 
before the operation as a substitute for a disclosing solution, 
as this staining will show up the tartar and other accumula- 
tions. It softens and loosens the attachment of accumula- 
tions. This "dressing" which we use comes nearer filling 



Post Operative Dressings. 405 

all requirements than anything yet found. It furnishes % the 
strongest anti-septic known and, when used in the mouth, 
it forms an astringent membrane which seals and protects 
from any infection. The formation of this preparation is 
similar to surgeons' collodion. It holds from twenty-four 
to forty-eight hours and gives the longest period of mouth 
medication known. We know that the surgeons of to-day 
are depending more and more upon iodine for sterilization. 
This "dressing" gives us the constant penetrating effect of 
this drug. Even though it had no antiseptic properties, the 
astringent effect upon the gums and the sealing of the gums 
to the teeth, would make it of great advantage. 

Many experiments have been performed outside of the 
mouth under all conditions but so far we have been unable 
to effect this peculiar formation outside of the mouth. 

The experiment may be tried of placing No. 1 on a dried 
section of the gum and the No. 2 over it; no combination 
takes place. Let the patient spit and the moment the saliva 
comes in contact with the preparation, a membrane is formed 
over the coated surface. Under twenty-four hours it is im- 
possible to remove the formation from the gums; after this 
time, it loosens and comes off in small pieces, resembling 
rubber dam. Instead of excessive hemorrhage from the 
operation, we have just the minimum amount. 

Outside of the mouth, on the hand, or anywhere, the prep- 
arations are put on in the same manner and covered with 
saliva under any and all conditions, but no formation takes 
place. Why? 

DIRECTIONS FOR POST OPERATIVE DRESSING. 

THE APPLICATORS. 

The applicators recommended are made by dipping the 
end of wood tooth picks into Sandarac Varnish, and twist- 
ing a few strands of dry cotton about the end, these make a 
secure and convenient swab for painting the gums. Several 



4o6 Practical Pyorrhea Alveolaris. 



AiMftJ*^*^ 



Zrr&SL 



& 



Fig. 116. 

hundred of these can be made in a few moments by your 
assistant, to be thrown away as used. It is absolutely essen- 
tial that a separate applicator be used for applying No. i 
and No. 2 preparations. 

The nose and throat specialist uses a long slander wood 
applicator which is also of great advantage in treating pyor- 
rhea. These can be used instead of the wood tooth pick. 

NAPKINS FOR DRYING THE GUMS. 

The application is greatly simplified by the use of small 
doilies which can be thrown away. These are inexpensive 
and used in all treatments about the mouth. Buy from your 
dry goods store, a bolt of English long cloth, costing about 
$1.00. Mark off the top of bolt into squares about 3x5 
inches, some longer, some smaller. Your printer will, with 
a few strokes of his cutter, convert the bolt into several 
thousand doilies. These should be sterilized and kept under 
cover ready for use. 

TECHNIQUE OF APPLYING DRESSING. 

Immediately after instrumentation and irrigation, the 
mouth is dressed -by drying sections of the gums with the 
aseptic napkins, which should be held so as to protect the 
lips and cheek while applying with applicator a coat of No. 
1 pyorrhea treatment, giving a moment for absorption; then 
freely paint over No. 1 with No. 2, letting it flow around 
and between the teeth; when the napkin is removed and the 
saliva comes in contact with the medicated gum, the com- 



Post Operative Dressings. 407 

bination of these two preparations forms a membranous 
coating or dressing similar to that produced by collodion 
as used by surgeons. 

As each section is treated, have patient rinse mouth with 
dental mouth wash. This at once removes the disagreeable 
taste and puckering of the pyorrhea treatment. Another 
section is dried and treated in the same way until all the 
affected teeth and gums are sealed. It is better to treat the 
upper jaw first. It is not necessary to have dressing extend 
more than 1-8 in. from gum margin. Be careful not to seal 
the ducts of Whorton and Steno, as this would cause a dis- 
agreeable swelling of the glands. 

The benefits of the iodine contained therein, we all know. 
The inflammation is deep seated, and iodine is the one agent 
that will penetrate. The astringent effect is produced by 
the tannin. This dressing draws the gums to the teeth; 
food, saliva, and toxic products are thus excluded. The 
blood-clot in pockets is protected until organized into new 
tissue. 

This dressing is not to be removed for 24 hours. See the 
patient regularly every day, removing the membranous or 
leathery coating of the day before from the gums by a gen- 
tle massage with a soft tooth-brush moistened in hot water; 
the mouth is sprayed with mouth wash, and the dressing of 
No. 1 and 2 is again applied. After a week of treatment 
it is not always necessary to use the No. 1 as the septic con- 
dition is under control, and the subsequent applications may 
be of the No. 2 alone. 

Sometimes, when an excess of these preparations is used 
on the gums, blisters similar to the so-called "fever blisters," 
appear in the mouth. When this condition arises, suspend 
all applications for a few days, until the condition disap- 
pears. 

The patient's name is engraved on his tooth brush using 
a small bur in the dental engine, and afterward is traced 



408 Practical Pyorrhea Alveolaris. 

with ink. The office assistant keeps these brushes in alpha- 
betical order in a small formaldehyde sterilizer. 

This brushing is done with the bristles lengthwise toward 
the gum. The brush is placed high up and the brushing is 
done with several objects in view. It not only removes the 
protective membrane of the AA Pyorrhea Treatment, but 
produces the best massage for the gums. The stagnant 
condition is relieved. New blood is enticed by this stimula- 
tion and the pressure forces some of the bacteria or its prod- 
ucts through its protective barrier or pyorrogenic mem- 
brane, which causes the blood to exert its fermentive prop- 
erties and act just as the use of a vaccine. 

At each sitting or treatment the brush is softened in warm 
water and the teeth brushed correctly, as described in the 
chapter on "Brushing the Teeth;" this removes the pyorrhea 
"dressing." I have always found it the best policy to brush 
the teeth myself, having the patient hold a mirror so that 
he can acquire the proper idea of using his brush. A strand 
of flat floss silk saturated with dentrifice is then run between 
the teeth and the mouth is sprayed out with dental mouth 
wash. The same process of dressing is made again and the 
patient dismissed for from twenty-four to forty-eight hours. 

After the patient has been treated about a week or ten 
days, he brushes his teeth before me at each sitting and in 
this manner he is compelled to get a good idea of the tech- 
nique of brushing his teeth. It is sometimes necessary to 
take the patient's hand and guide him into brushing correctly. 
After being taught in this manner, if the patient comes up 
in the future with case of oral sepsis, no one is to blame but 
the patient himself. 

After treating the patient in this way from two to four 
weeks, and I am fully satisfied that the necessary tissues have 
formed to resist the force of mastication, and all signs of 
inflammation have subsided, several hours are spent in pol- 
ishing the teeth. Sometimes, I am surprised to find that so 



Auto-Intoxication. 409 

much tartar has escaped my notice and every bit of it will 
be shown up by "AA Pyorrhea Treatment Nos. 1 and 2." 
I now turn my attention to this and every scale of accumu- 
lation is removed with the scalers, the porte polisher or the 
polishing wheel. 

This "treatment" on account of its staining qualities is not 
for the lazy dentist, but in the hands of a careful man gives 
the greatest opportunities for making the mouth perfectly 
clean and for instructing the patient in the proper keeping 
of his mouth. Its use has proved gratifying both to the 
patient and myself. 

Before dismissing our pyorrhea patients, we must have 
them understand that where the gum is receded and the 
dentine is exposed, tartar is more readily collected and that 
these surfaces must be kept free from all accumulation. For 
this reason, these patients are dismissed only on probation 
and they are instructed to return in a month for inspection, 
when they are again taken through the "tooth brush drill." 
We endeavor to persuade all the resident patients to take up 
our system of monthly prophylaxis either under our own care 
or that of a dental nurse. 

AUTO-INTOXICATION IN PYORRHEA. 

Many investigators have attributed auto-intoxication as 
the cause of many cases of pyorrhea. Intestinal complica- 
tions should always be suspected and the proper attention 
given thereto. 

The large amount of filth, germs, and parasites in a pyor- 
rhea mouth which is constantly swallowed or mixed with 
food must in time affect the stomach or intestines. It is not 
probable that the secretions of the stomach can at all times 
handle this material from the mouth. When it is passed 
into the intestines some of this toxic matter is absorbed by 
the intestines, its structure may become diseased, or the blood 
become saturated with some form of this toxic matter. 



410 Practical Pyorrhea Alveolaris. 

On the other hand, there is as much argument to support 
those- who start with a sluggish liver, inactive kidneys, con- 
stipation, germ-infected fecal matter, inadequate elimination 
with its resultant auto-intoxication thrown into the blood 
stream to afterwards break out at some location as for in- 
stance, the gums around the teeth. But the question comes, 
would it do so unless the gums were already diseased? No 
matter which way we believe, the condition is serious enough 
for consultation with a physician who should recognize the 
gravity of the situation and cooperate with the dentist by 
prompt and energetic treatment, for there is nothing we can 
do to hasten the cure of a case of pyorrhea under treatment 
as much as the re-establishment of the proper elimination 
process of the intestines. Bear in mind that auto-intoxica- 
tion generally occurs in those who indulge in excesses of food 
and drink. Reduce the foods containing animal proteids. 
Meat must be forbidden as a food. Fresh buttermilk or 
some of the artificial varieties must be taken in large quan- 
tity to reduce the fermentative process in the intestine by 
its anti-fermentative property. Insist that the patient drink 
a large quantity of water, preferably lithia, each day. 

The commercial houses by their attractive literature sug- 
gest many wonder-working preparations, but just plain old 
epsom salts will do the work. Begin by prescribing one 
tablespoonful in water every other morning for four morn- 
ings, then reduce to one teaspoonful each morning for one 
week. 

SILVER NITRATE IN PYORRHEA TREATMENT. 

One of the most valuable applications the eye, nose, or 
throat specialists use is some form of silver salt or solution. 
If properly used, they would be just as great an adjunct in 
our pyorrhea cases. I have records of cases treated suc- 
cessfully with silver salts when all other methods had proved 



Silver Nitrate in Treatment. 411 

a failure. On the other hand, their use has proved of little 
value in many cases. 

Indications, i. During your operative procedure, if 
you find some surface so sensitive as to cause the patient dis- 
comfort, no matter what treatment is used, silver nitrate is 
indicated. 

2. If during the post-operative treatment some of the 
gum tissue will not contract, and remains flabby, the applica- 
tion of silver is beneficial. 

3. When the final polishing is done, and patient is about 
to be dismissed, the operator should take note of all sur- 
faces which present the appearance of semi-decay. Some- 
times where the roots of the teeth are exposed, we will find 
this condition to exist almost completely around the tooth 
at the enamel root junction. It has been proved beyond 
question that this treatment will prevent these surfaces from 
decaying. 

The Application of Silver Nitrate. — All porcelain 
inlays, silicate or cement fillings must be well coated with 
sticky wax to prevent the permanent staining of nitrate of 
silver. The neglect of this precaution has caused many 
operators considerable embarrassment. A ten per cent, solu- 
tion of silver nitrate will not discolor, and should be used on 
front teeth. A 40 per cent, solution offers the best general 
treatment. In stubborn cases, a saturated solution may be 
used. The bottle containing this solution should be wrap- 
ped in dark paper and kept in a dark place. Standing solu- 
tions soon deteriorate. In the application of silver nitrate 
to teeth, the surface treated should be kept dry by the use 
of cotton rolls, not only during application, but for a few 
moments afterwards. 

When a strong effect is desired and we do not wish to in- 
clude the soft tissues, the following method is applicable. 
A suitable wire (bronze, platinum, or platinoid) is mounted 



412 Practical Pyorrhea Alveolaris. 

in a handle, the point heated and dipped into a bottle con- 
taining crystals of silver nitrate. The adhering crystals can 
then by great heat be melted into a bead. This gives a 
small silver nitrate stick which can be rubbed on the tooth 
direct without affecting the soft structures or soiling your 
hands. 



CHAPTER XXXIII. 
SPECIAL OPERATIONS IN PYORRHEA. 

IMPLANTATION. BIFURCATION TREATMENT. REMOVAL OF 

PULPS. AMPUTATION OF ROOTS. TREATMENT OF 

PYORRHEAL ABSCESS. BRIDGE WORK IN PYOR- 
RHEA. SPLINTS. 

IMPLANTATION. 

For many years the experimental surgeons in dentistry 
have endeavored to find some system whereby lost teeth 
could be replaced in the jaw by other human teeth. Dr. 
Younger was one of the first to make a success of this opera- 
tion and it is to be doubted whether his first technique has 
been improved upon. 

Dr. Kells also makes the practice of the implantation of 
one missing tooth, but these are planted in a favorable situa- 
tion. I have seen in his office a lower molar tooth that had 
been implanted for seven or eight years. 

Dr. Robert Good is doing a great deal of this work in 
pyorrhea cases. His method is so unique and original that 
I will describe it in detail as I have seen it carried out in 
his office. 

Dr. Good's assistant haunts the places where teeth are ex- 
tracted, hunting for peculiar kind of teeth. The tooth he 
wishes is that of an old person, especially if it has an ex- 
otosis on the end of the root. The search is evidently suc- 
cessful, for he has large jars of these kept in liquid in his 
laboratory ready for selection on a moment's notice. 

Dr. Good seems to think it a very simple matter, if one 
can not cure a tooth affected with pyorrhea, to extract the 
tooth, clean it off, deepen the socket, and force the tooth 



414 Practical Pyorrhea Alveolaris. 

back, secured by a retainer of twisted linen or silk thread. 
If the tooth is out of line, which they frequently are in pyor- 
rhea work, it is rotated with one movement of the forceps. 

However, the most original work which I saw was where 
an upper molar tooth was needed for an attachment for a 
bridge. A new socket was bored at about the position of 
the second molar and a large cuspid root, with the crown 
cut off, was driven tight into place. Previous to the inser- 
tion, he had made a platinum coping so as not to disturb the 
root when he was ready to make this bridge. 

He uses no special instruments other than a Younger root 
reamer. The canal is properly filled and the tooth, having 
stood in a strong solution of lysol while the socket was being 
made, without being washed off, was driven home tight. 
After such a tooth has stood for some four or five months 
it is generally ready for bridge work. 

For the encouragement (?) of those who wish to try this 
for bridge work in pyorrhea cases, I will say that I have 
tried it on several teeth, but to this date I have never been 
able to get one to stick in a pyorrhea case. 

Another method of replacing pyorrhea teeth when they 
are needed for extra abutments for bridge work is by insert- 
ing some device made of metal; one of these is made and 
sold by Dr. Greenfield, of Wichita, Kans. It is a platinum 
frame work made in a circle which is inserted into the jaw 
to fit the trefined socket which has left a central core. This 
method, while possibly the best one now in vogue for attach- 
ing teeth to a bridge at the alveolus, is not so successful in 
pyorrhea cases, because the alveolus, having been partially 
absorbed, does not give the proper support. 

To those who desire to experiment along this line is sug- 
gested the following method, which has been tried by sev- 
eral of our practitioners: either drill a new socket or use the 
old one and select a common wood screw with large threads 
which will fit the socket tightly. This having been fitted and 



Bifurcation Treatment. 415 

cut off to proper length, is unscrewed, the impression taken, 
and cast in either tin or silver. A hole is drilled in the larger 
end and the coping fitted. The cast screw is then forced 
into place and after a few weeks, when the tissues have 
about resumed their normal state, the crown or bridge is 
fitted thereon. 

After implantation, by the use of AA Pyorrhea Treat- 
ment we are enabled to seal the gums to the teeth, prevent 
infection and keep out all food particles. This preparation 
will hold from 24 to 48 hours, is an astringent, and really 
acts as a splint, drawing the gum close to the teeth. 

While there are some men who seem to be making a suc- 
cess of implantation work, it can not be said that it is as 
great a success in pyorrhea cases; greater absorption of the 
alveolus having taken place together with the greater danger 
of infection, makes the chance for holding less than in a 
healthy mouth. Still this is a great field for research work 
and it is to be hoped that at some future time methods will 
be devised for overcoming these difficulties. 

BIFURCATION TREATMENT. 

When there is an exposure of the bifurcation of multi- 
rooted teeth, especially the lower molar or buccal roots of 
the upper teeth, Smith suggests making a positive retention 
cavity between the roots and filling this with hard gutta- 
percha, forcing it, while soft, against the process and gums 
and finishing it flush with the tooth. He says, further, that 
this simple procedure will arrest all recession at this location. 

The copper cements also give excellent results in good 
locations and have the advantage of moulding over the gum 
tissue without pressure and into nooks where it is difficult 
to place gutta-percha. 

Use cement in a jiffy tube and place finger on opposite 
side to confine it to the tooth, bone, and gum. The latest 



4i 6 Practical Pyorrhea Alveolaris. 

thing I have tried which seems to have proved a success, is 
the following method : 

Select two gutta-percha pulp canal points which will 
nearly fill the space between the exposed roots. This space 
is then protected, dried, and swabbed out with a twenty-five 
per cent trichloracetic acid solution to cauterize and stop 
any bleeding. Acetone is next applied to the surface so 
the cement will stick. The previously selected gutta-percha 
points are now covered with copper cement mixed thin. 
One of these is run through bifurcation from buccal side, the 
other from the lingual side, passing each other in the center. 
Wait until cement gets hard, then with disk and hot instru- 
ment finish filling on both sides. By this method the oper- 
ator knows the cavity is filled, no undue pressure is exerted 
on the bone or gum and is easy to accomplish. This proce- 
dure will save teeth that otherwise must soon be doomed for 
the forceps. 

REMOVAL OF PULPS. 

Whether or not it is best to remove pulps in operating 
for pyorrhea, is a subject which has not been agreed upon. 
There are operators of well known ability who never de- 
stroy a pulp if they can avoid it. Other dentists, equally 
capable, destroy pulps in pyorrhea work. These latter men 
claim that in the removal of the pulp, the nutriment is di- 
verted to the outer surface of the tooth, where it is most 
needed. It has not yet been explained by these operators, 
the modus operandi of this changing of nutriment. They 
claim that a devitalized tooth is never attacked by pyorrhea, 
but it has been borne out by observation that this is not true, 
nor does the author deem it advisable to remove the pulp 
of the tooth for the purpose of curing pyorrhea, for if 
there is ever a time when a tooth needs all the vital force 
and nerve energy which it originally possessed, it is at the 
time when it is lame from pyorrhea; whatever results have 
been attained from the removal of pulps, were in those ad- 



Amputation of Roots. 



4i7 




Fig. 117. Teeth representing a condition of hypercementosis frequently 
met with in pyorrhea cases. To attempt to remove the pulps and fill the 
canals of such teeth as these is beyond the skill of most dentists. 
From an examination of just the crowns of these teeth they would be 
thought normal. (From author's collection.) 



vanced cases, where the pulp was infected by the extension 
of the disease or was cut off by tartar deposits at the end 
of the root. Such teeth are generally extracted, but the 
teeth which we leave for operative procedure seldom have 
pockets extending to the end of the roots. It is not advisa- 
ble to remove these pulps. However, if extra sensitiveness, 
due to infection, is a constant symptom, it is advisable to 
remove the pulp; remember that it is a peculiar coincidence 
that teeth affected with pyorrhea seem to have the most 
crooked roots. (Fig. 117.) 



AMPUTATION OF ROOTS. 



If, on examination, the probe can be pushed entirely 
around the root of any multi-rooted tooth, and over the 



4i8 



Practical Pyorrhea Alveolaris. 



apex, then it is useless to attempt to save this root as it 
only constitutes a foreign body, and together with the sur- 
rounding pocket, forms a trap for future infection and food. 
In such cases, provided the other root or roots have good 
attachment, amputation of the offending root may be effected 
and the remaining portion of the tooth made to do service 




Fig. 118. Amputated roots from pyorrhea cases. (A) The largest mass 
of serumal calculus which the author has ever seen under the gum mar- 
gin. It resembles a clump of oysters. (B) Calculus at end of root. 
(C) Lower molar root removed because bone was destroyed on two 
sides. (D) Eroded root. (E. F. G.) Removed because of loss of 
bony support. (H. I.) Serumal calculus. (J. K. L. M.) Root ab- 
sorption. (N) Excementosis. The teeth from which these roots were 
amputated all did good service. Some few had to be extracted after 
several years, but others seem to be as good teeth as any the patient 
has. Some of the above are bearing bridges. (From author's collec- 
tion.) 



Amputation of Roots. 419 

for years. There has been a great deal written on the sub- 
ject of amputation of roots for alveolar abscesses, but few 
men outside of specialists in pyorrhea seem to have realized 
the great value of this simple surgical procedure. 

I have performed this operation successfully in several 
hundred cases. Many of these teeth so operated on over 
eight years ago, are still proving successful abutments for 
bridges. I am therefore led to urge upon the general prac- 
titioner the adoption of this procedure as a routine method 
in suitable cases. 

Many dentists with whom I have talked, have expressed 
the idea that it is extremely difficult, and that they were 
afraid to undertake it. This is an erroneous supposition; 
the field for operation is uncomplicated by any important 
anatomical structures, such as nerves or arteries, and is 
easily accessible, without much cutting or the necessity for 
an anesthetic. In pyorrhea work this operation is confined 
to multi-rooted teeth, that is, molars. The one thing to 
be decided before determining to amputate the root of the 
tooth is that the disease and the destruction of the surround- 
ing bone is confined to this one particular root. 

The most frequent places where amputation is needed 
are: first, the palatal root of the molars; second, the pos- 
terior buccal root; third, the anterior buccal root. On the 
lower molar teeth we most frequently amputate the pos- 
terior roots; these are the most difficult roots that we have 
to remove. 

This operation, to be satisfactory, requires that the root 
be normally separate from the other root, or roots, that is, 
they must not be fused together for their full length. The 
small curved probe or pyorrhea instrument can be intro- 
duced between the roots to determine this. If the root is 
anastomosed almost to the top with its adjoining root, the 
case is not one for successful operation. This caution ap- 
plies particularly to the buccal root of the upper molar, as 
it is very seldom that a complete union of the palatal root 



420 Practical Pyorrhea Alveolaris. 

or the lower molar root takes place. Before beginning 
the operation, it is advisable to remove the pulp of the tooth 
and fill the pulp canals in the best way possible, for after one 
of the roots is taken out, it is very difficult to find the canals. 
However, the writer has frequently removed roots of teeth 
without paying any attention whatever to the tooth pulps, 
for the shock of going straight through so paralized the 
nerve that there was little pain to the operation. The best 
instrument for this operation is a long shank cross cut fissure 
bur. This is to be used in a right-angle hand piece. The 
bur is introduced in the bifurcation and with engine revolv- 
ing rapidly give the hand piece a saw-like motion towards 
the crown of the tooth; this produces the proper slant for 
easy removal of roots and self cleansing space; the angle at 
which we point the hand piece towards the crown of the 
tooth has all to do with the easy removal of the separated 
root. As a general thing, after separation of the root, it 
drops back into the pocket which surrounds it and can be 
easily withdrawn with a pair of pliers. As the tooth upon 
which we are operating may be loose, the operator always 
braces the tooth securely, either with his hand or by placing 
a small amount of warm modelling wax against several of 
the teeth, making a brace so as not to have any undue force 
on the part of the tooth which we wish to preserve. 

It is not advisable to start on one side of the tooth and 
later remove the bur and again begin from the other side 
of the root, as this makes a ragged operation. However, 
this may have to be done in some cases. The root having 
been removed, the next step is to polish the surface from 
which it was removed, so that there will be no sharp or 
jagged edges to irritate the gums or catch food. If the 
tooth is a large upper first or second molar, it is sometimes 
advisable to remove that part of the crown of the tooth 
that overhangs the place where the root came from, as too 
much leverage would tend to tip the tooth in that direction. 
This is not so necessary in the lower jaw, as here the crown 



Treatment of Abscess. 421 

of the tooth is braced by the adjoining tooth. The socket 
from which the root was extracted needs very little atten- 
tion except to be thoroughly washed out with warm water 
and some mild antiseptic solution to keep it free from food 
until it fills up. In some of our cases it is hard to tell that 
an amputation has been done, as the gum soon falls into 
place where the root was removed. 

As this operation is performed in such a manner that the 
parts are easy to keep clean, it has not often been found that 
any decay set in from exposure of dentine. Sometimes it is 
very important to make correction of malocclusion in these 
teeth in order to prevent any undue force being put upon a 
tooth which is naturally weaker than normal. In fact, it is 
a good idea to lower the occlusion on a tooth from which 
a root has been taken. 

The prettiest result of root amputation is where the re- 
maining part of the tooth is to be used as a bridge abut- 
ment. Every abutment which can be used in bridge work 
adds to its strength and should be saved, especially in pyor- 
rhea mouths where all the rest of the abutments may be in 
a shaky condition. We have all observed in a boat landing 
where piles were being driven, that one or two of them 
seemed loose, but when lashed together an ocean steamship 
could hardly shake them. In the same way it is desirable 
to give every possible support for bridge work, even though 
some of them, alone, may seem very weak. 

In using these teeth for bridge abutments it is desirable 
that the whole of the crown be removed and small platinum 
coping be placed just under the gum margin. I have al- 
ways found this to be easier and of better success. 

TREATMENT OF PYORRHEAL ABSCESS. 

If the operator is familiar with the formation of a pyor- 
rheal abscess (described on page 321) the treatment is a 
simple matter. 



422 



Practical Pyorrhea Alveolaris. 



The patients come in very much alarmed at the sudden 
condition of one of their teeth. This alarm can be quickly 
turned to quiet and confidence if the proper treatment is 
given. 

Do not attempt to lance the swollen area, but with a 
Younger instrument, Number i or 2, carefully insert at 
cervical edge between gum and tooth toward the swelling. 
This should not hurt the patient; almost the weight of the 
instrument will be sufficient to enter the pocket and allow 
the pus which is under pressure to escape. Now, at this 
stage, do not attempt to do any root scraping or planing, 
but with a small pointed syringe insert at the point where 
the instrument was passed and using gentle pressure wash 
out the cavity. Repeat this several times. Do not use any 
strong irritating liquids, but use either hot normal salt 
solution or water with phenol, five drops to six ounces. This 
operation should be repeated the following day. 

At some subsequent date when the tissues are less pain- 
ful, the tooth should be treated for the pyorrheal condition. 

BRIDGE WORK IN PYORRHEA. 

In treating a case of pyorrhea, bridge work is often nec- 
essary. The character of this work has a great deal to do 




Fig. 119. 



Style of Bridge Work Most Useful in Pyorrhea Mouths 
(Thierch). 



Bridge Work in Pyorrhea. 423 

with the permanency of our results; many specialists prefer 
to do this mechanical work themselves according to their 
own ideas, and in fact, one or two specialists will not accept 
a case referred to them by other dentists, unless this pro- 
vision is made. The reason for this is that considerable 
deviation from the regular established system of bridge 
work is often indicated, in that we have to use more teeth 
for support than we would in a normal mouth. 

In the construction of this work all sides of the abutment 
teeth should be accessible for instrumentation, and the cen- 
tral idea for bridge work of this kind is that it must be so 
constructed as to be easily cleaned by the patient. This 
fact is sometimes lost sight of by the mechanical man whose 
sole idea is to restore the lost teeth and to fill the space 
completely. 




Fig. 120. Lingual Surface, Upper Jaw, Bridge Work in Pyorrhea 

Cases 

After finishing our treatment, if we find several teeth still 
loose and several to be replaced, we can not only replace the 
lost teeth, but can bind the loose ones together, furnishing 
the best kind of splint. Thus the pressure is distributed 
over a larger area so that it is not too great on any one 
tooth. For any extensions on the bridge, it is well to make 
saddles to extend on either side of the alveolar ridge so as 



424 Practical Pyorrhea Alveolaris. 

to give the extension support from lateral strains. All 
soldering of abutments should be as near the occlusal sur- 
faces as possible, so that we may have better access to the 
root surfaces in case a pocket develops there at any time. 
Smaller amounts of solder can be used if platinum wire is 
soldered or waxed in and cast into the abutments at the 
places of joining. 

SPLINTS. 

Many varied and ingenious devices for the retention of 
loose teeth in pyorrhea have been described in dental jour- 
nals and demonstrated in clinics; the author discusses, in 
the following pages, the use and making of splints. 

The very fact that teeth have to be splinted in order that 
they may be saved, makes them a source of frequent infec- 
tion, and they will need frequent attention from the dentist 
to keep them in proper shape. 

Splints are of two kinds, temporary and permanent. The 
temporary splint is of greatest advantage. It is sometimes 
well to use some form of temporary splint at the time of 
operation so as not to give the teeth too much strain dur- 
ing the operation. If this is not done, it is well to do so 
after the operation, so as to give the teeth a rest and chance 
to regain some strength. This applies particularly to the 
lower anterior teeth and the superior laterals. 

Perhaps waxed floss silk, laced in between the teeth in 
figure 8 fashion, forms the best temporary splint; this can 
be removed every day or two. To prevent the splint from 
slipping down into the gums a little cement can be placed 
upon the surface of the teeth. Orthodontia wire is also ex- 
cellent for this purpose. Dr. J. W. Jungman suggests the 
following: "Roll out the ordinary Angle orthodontia wire 
to a ribbon; anneal and gold plate. Start from left to right 
by forcing the wire down between the bicuspid and cuspid; 
then lace it, carrying the strands over and under so as to 
lock them. At the right cuspid, wind one strand around 



Splints. 425 

the other, and force it between the cuspid and bicuspid so 
as not to irritate the lip. Where there are one or two loose 
teeth, I usually carry to the adjoining teeth only." 

Dr. Spies' illustrations show a form of temporary wire 
splint which need not be changed, is clean, and if properly 
applied does not draw the teeth together as does the silk. 
It is made by using 26 gauge gold ligature wire for the slip- 
noose and 30 gauge for the wires between the teeth. Make 
a slip-noose over the teeth to be enclosed, by bringing one 
end of the wire over the other, but not twisting them to- 
gether. Cut short pieces of wire to be used between each 
two teeth, twist the ends together, and draw tight. These 
wires should be cut to such length that the ends may be 
turned back into the interproximal space without touching 
the gum tissues. The ends of the wire of the first slip- 
noose should now be twisted together. 




Fi<;. 121. Temporary Wire Splint (Spies). 

Dr. Robert Good's method of ligating teeth is to use A, 
B or C sewing silk, having it well waxed. Select tooth for 
anchorage, then pass ligature twice around this tooth (mak- 
ing double loop) and fasten by making double knot and 
single knot on top double one. Now make single loop 
around next tooth and make knots the same as before and 
continue in this manner, until you have included the number 
of teeth you wish to ligate or make fast. When the last 
tooth to be included is reached, make double loop again and 
return, making the loops the same as before, this will give 
two rows of ligatures, making the teeth quite rigid. Three 



426 Practical Pyorrhea Alveolaris. 

rows or more may be used, making a splint that will remain 
for six or eight weeks. Care should be taken to place the 
ligatures on the teeth in a position where they will slip 
neither up or down, but remain where placed. 

In using these temporary splints, it is well to be certain 
that no undue strain is placed on the teeth, pulling them out 
of position. Where space exists, many knots may be tied 
to bridge this, or the wire twisted between the teeth, so 
as not to draw them into the space. 

The writer has seen cases where the wire was placed for 
temporary splints to be removed at a stated time, but for 
some cause the patient got away without its being removed, 
and it remained several years without discomfort. Wire 
has the advantage of being easily put on and easily replaced; 
it shows no metal and is easy to keep clean. If it is de- 
sired to be permanent, little nicks can be cut with a fissure 
bur run between the teeth; this will hold the wire secure and 
prevent it from slipping into the gums. Sometimes a little 
cement to hold it in place will last for years. The advent 
of cast work has opened a new field for the ingenuity of the 
operator in the line of dental splints; small inlays can be 
made which are easily inserted and this will probably be 
the means adopted for splints in the future. The old 
method of swaging these splints and soldering them up did 
not produce the results which we hoped it would. 

In devising the splint, the main requisite is to hold the 
tooth rigidly in its proper position. It must be self-cleans- 
ing or easily cleaned by the patient. Again, it must not 
extend to the gum margin to fill up the interstitial space, 
but must be left so that instrumentation of the root surface 
can be done with ease. 

A serviceable splint for the anterior front teeth can be 
made by shaping the cutting edge of the incisors much like 
a facing for bridge work. Cut in enough to allow a good 
thickness of gold, with a small round bur in the right angle 



Splints. 427 

handpiece, drill two holes straight down parallel with the 
tooth, an inch, straddling the pulp on either side. Each 
tooth to be splinted is treated the same way. Into these 
holes iridio platinum pins are fitted, leaving them sticking 
up slightly above the tooth. Some use pins from vulcanite 
teeth, but a threaded wire cut into pins the proper length is 
stronger and more retentive. Over the ground surface of 
the tooth is burnished a small disc of thin gold plate. The 
pins for each tooth are stuck through each little finished 
plate and stuck into sticky wax. The burnished plate with 
two pins is removed, invested, and soldered. When all the 
teeth to be splinted have been so treated, the disks contain- 
ing the soldered pins are placed on all the teeth and the im- 
pression taken. As the pins were left protruding, if any 
of the disks fail to come off in the impression, they can be 
replaced in position. Modeling compound is to be pre- 
ferred for this impression. A small model is made of any 
material on which we can solder. 

Some operators prefer to just wax up these pins, place 
on multiple sprue wires and cast. Considerable experience 
with this class of splint convinces me that we can not get 
as good piece of work as in the way I have described. 

After the model is separated, one or two platinum wires 
are bent around similar to the lingual plate bar touching 
some point on each disk on model. The wire should be 
very small. Sometimes two wires can be used. This is 
tacked with solder to all of the discs. These wires add 
much strength, but the greatest advantage is that we can 
now at this stage readjust the alignment of all pins and 
reburnish the discs so that when the work is finished we 
know it will go evenly to place. The work is now waxed 
up in the mouth with a small amount of wax and cast, or 
just as good, solder flowed over the whole and finished. 
I have not found any other device that will do it as well as 
this splint, made the way described. Where one of the 



428 Practical Pyorrhea Alveolaris. 

four anterior lower teeth is missing, abutments made as 
above, and placed on each side, will support a missing tooth. 
However, after all is said and done, it seems to me it 
is not of the most benefit to retain the teeth which have to 
be placed in splints, and it does seem to be the best policy 
in the beginning to extract those teeth which the operator 
will soon learn by experience will never be kept in a healthy 
condition, and which may require extraction later on. 



CHAPTER XXXIV. 

VACCINES AND EMETINE IN THE TREAT- 
MENT OF PYORRHEA 

AUTOGENOUS VACCINES IN THE TREATMENT OF 
PYORRHEA. 

The author has been so successful in treating pyorrhea ac- 
cording to methods described elsewhere, that the subject 
of vaccines has not had much attention in his practice. In 
discussing this subject at the last National Dental Associa- 
tion in Washington, Dr. Rhein made the statement that 
when vaccination became necessary, the ordinary dentist was 
not a necessity because the patient was a fit subject for the 
hospital. 

In order that the reader of this book may become fa- 
miliar with the elementary facts on which this treatment is 
based, I give the following article by Dr. George B. Harris, 
which was published in the Dental Summary : 

"The use of vaccines in the treatment of pyorrhea is not to take 
the place of the local treatment of instrumentation in any way. How- 
ever, it becomes a very valuable agent when used to overcome the 
infection present and in maintaining a condition that makes the 
growth of bacteria impossible over a period of sufficient length to per- 
mit regeneration. It not only does this, but it also prevents the re- 
currences of pyorrhea after a cure has been effected by fortifying the 
individual against the bacteria. Protection against recurrence is as 
important as a cure itself. Stock vaccines may be used to do this, but 
it has been my experience that the Autogenous Vaccines give from 50 
to 75 per cent, better results. 

"The first step in making a vaccine of this kind is the obtaining 
of the pus. This should be obtained in as pure a culture as possible. 
Carefully remove all tartar deposits from the teeth ; paint the tooth 
and gum with iodin and dry. On the following day remove all food 
particles, dry with alcohol again, paint the gum with iodin, and dry. 
Then carefully force out a small amount of pus from under the gum, 



430 Practical Pyorrhea Alveolaris. 

collect on a sterile platinum wire and inoculate an agar tube. Allow 
this to germinate from twenty-four to forty-eight hours. If a pure 
culture has been obtained, which is generally the case if the preceding 
operations have been carefully done the vaccine may be made directly 
from the first culture and several days saved ; otherwise new cultures 
must be made from the predominating culture in the initial tube. 

"Remove as many of the cultures as possible, care being taken not 
to take up any agar with the cultures. These are now transferred to 
a tube containing distilled sterile water. This is shaken vigorously to 
break up all clusters. A centrifugal machine should be used for this 
purpose, but if one is not to be had it can satisfactorily be done by 
hand. One-half a cubic centimeter is now drawn up and transferred 
to another test tube. This is used in the determination of the number 
of bacteria we may have in the concentrated solution and is not made 
into vaccine. To this is added two cu. cm. of water to make the 
counting easier and more accurate. About half a cu. cm. of this di- 
luted solution is now drawn up in an opsonizing pipette and an equal 
amount of normal blood taken directly after. This is blown out on 
a slide and mixed. A drop is then placed on a cover glass, dried, 
mounted and stained. Place the slide on the counting chamber and 
count the corpuscles and germs in the successive fields until at least 
250 corpuscles are counted. Since there are 5,000,000 corpuscles in 
a cu. mm. of blood, by a simple proportional equation we can deter- 
mine the number of bacteria in the dilute solution. By multiplying 
the number of germs in the dilute solution by the number of times 
it was diluted, we determine the number of germs in the concentrated 
solution per cu. mm. Since there are 1,000 cu. mm. in a cu. cm., by 
multiplying the number per cu. mm. by 1,000 we determine the num- 
ber per cu. cc. For example : Suppose we counted 250 corpuscles and 
50 bacteria. Since we know that there are 5,000,000 corpuscles on 
one cubic millimeter of blood, the following proportion is established : 
250 15,000,000 : :5b :X. 

"Solving this proportion, we find there are 1,000,000 bacteria per 
cu. mm. Since there are 1,000 cu. mm. in a cu. cc. we find 1,000,- 
000,000 bacteria to each cu. cc. in the dilute solution. Since we di- 
luted the solution four times, there are 4,000,000,000 bacteria to each 
cu. cc. in the concentrated solution. The vaccine is now ready to be 
standardized. It is first diluted to the strength we wish to have it; 
heated at 60 degrees for an hour, then 4 per cent, tricresol added to 
prevent contamination, and sealed. 

"Any loose tissue may be selected as the site of injection. The 
most important things to look out for are: 

"1. Be sure the solution is sterile. 

"2. Absolute cleanliness of the skin at the site of injection. 

"3. Use great care in avoiding veins. 

"4. Be sure the count is accurate." 



Autogenous Vaccines. 431 

Dr. Merritt was one of the first to use the vaccine treat- 
ment and read several papers advocating this treatment. 
Of late he has been convinced that he was wrong and now 
strongly condemns the treatment. Dr. Merritt says: 

"The first requisite to success in the vaccine treatment of 
any disease is to establish the casual relationship of the or- 
ganisms to the disease under consideration. Since each or- 
ganism provokes in the body its own specific ferment, which 
has no influence whatever upon the organisms of unlike 
nature, the importance of clearly establishing this relation- 
ship will be obvious. So sensitive is this balance between 
organism and ferment that the slightest variation in type 
may render the vaccine worthless. In nothing is absolute 
accuracy of more importance than in vaccine therapy. When 
it is realized that at present there is not the slightest proof 
that any of the organisms associated with pyorrhea sustain 
any casual relationship to it, the irrationality of selecting one 
or two types out of the vast host of organisms present, and 
making these the basis for vaccine treatment, must be self 
evident. In the light of our present knowledge, vaccines 
of this character have no place whatever in the treatment of 
this disease." 

The dental profession has not realized a great amount 
of success by the use of vaccines in pyorrhea treatment, for 
the reason that it does not reduce the responsibility of re- 
moving every bit of material containing the infection so that 
a vaccine could be effective. When this is done, there is 
little need for the vaccine, for the blood is generally able to 
take care of any infection whicfi is placed in contact. When 
the blood is so low in character that it can not do this, the 
patient is rather beyond dental treatment and needs the ser- 
vices of the physician and hospital. 

The use of vaccines may be of service to fortify the pa- 
tient against reoccurrence after the treatment, but is doubt- 
ful whether the length of time this protection would last 



432 Practical Pyorrhea Alveolaris. 

is worth the trouble of making and administering the vac- 
cine. A better protection would be the proper training of 
the patient to keep the local conditions in a healthy state. 

TREATMENT BY EMETINE. 

The amebae found in the mouth seemed to be similar to 
the organism causing tropical dysentary. As emetine, the 
principal ipecac alkaloid, is required as a specific for this mal- 
ady, the investigators at once suggested its use in the mouth 
and system to cure pyorrhea. 

Dr. Barrett used the ordinary hypodermic syringe with 
suitable point, injecting emetine hydrochloride half per cent, 
into each pyorrhea pocket. The needle was placed as far 
as the bottom of the pocket, then gradually flooding the 
pocket as the needle was withdrawn. The injection should 
be repeated daily for a week, then, every day for a period 
of ten days. 

Dr. Bass, in addition to pocket application, injected the 
drug subcutaneously, with the idea that local application 
could not reach all the diseased area. The injection con- 
sists of one-half grain emetine hydrochloride hypodermic- 
ally into any convenient part of the body daily for three 
or four days. Then wait about one week and repeat the 
injections. He further advises the administration by mouth 
the tablets of Alcresta Ipecac. This preparation passes 
through the stomach unchanged and liberates the ipecac in 
the intestines to be absorbed into the circulation. These 
tablets are given two or three at a time an hour before meals 
reducing the dosage if a diarrhea is produced. These tab- 
lets seem to be as efficient as hypodermic injection, and elim- 
inate the disagreeable injection. 

Heinz' "Fifty Seven Varieties" is not in comparison with 
the large number combinations of ipecac and emetine which 
the drug houses were quick to offer the dentist and patient. 
Their attractive literature leads one to believe that if only 



Treatment by Emetine. 433 

that particular brand of emetine pill, emetine mouth wash, 
or emetine dentrifice be used, positive relief can be afforded 
the patient. 

On May 6th, 191 5, Dr. A. H. Merritt read a paper re- 
cording his experiments in looking for the endameba in 
pyorrhea cases and the treatment by emetine before the 
Massachusetts State Dental Society at Boston. From this 
interesting article a quotation at length is given: 

In view of the widespread interest aroused by the announcement 
that the endamoeba buccalis is the direct cause of pyorrhea (18) (19) 
and that as a result of its destruction by emetine there is marked 
improvement in the disease (in not a few instances practically curing 
it) makes it necessary to inquire into the claims made by the advo- 
cates of this treatment. In the Proceedings of the New York Patho- 
logical Society, 1907, Dr. L. T. LeWald presented a preliminary 
report of investigations which he had been carrying on as to the 
occurrence of amoeba in the mouths of healthy individuals. In this 
report he says he was able to convince himself that these amoeba 
could be demonstrated in the mouth almost constantly, no matter 
how much care was taken of the teeth. In the first examination of 
one hundred cases, he obtained positive results in seventy-one. In 
going over some of the negative cases, he found amoeba in four 
more, and he felt that with repeated examinations they could be 
demonstrated in most if not all the others, and concludes his report 
with these words: "there was left in my mind no doubt as to their 
presence in the human mouth in health, equalling in this respect, 
the presence for instance of the bacillus coli commis in the intestines." 

In a paper entitled "Amoeba in the Mouths of School Children," 
read before the New York Pathological Society in March, 191 5, Dr. 
Williams, Assistant Director of the Research Laboratories of the 
New York Health Department, reported the result of an examina- 
tion made by that laboratory. 

A preliminary examination was made of 475 school children, be- 
tween the ages of 9 and 16. 150 were chosen as representative cases, 
and subdivided as follows: 

1. Healthy gums, no caries 20 

2. Healthy gums, carious teeth 22 

3. Tartar and receding gums 47 

4. Spongy and bleeding gums 65 

From most cases, two smears were made, the teeth and gums hav- 
ing been previously cleansed with a cotton swab dipped in 50% 
alcohol. These smears were then examined for amoeba, with fol- 
lowing results: 



434 Practical Pyorrhea Alveolaris. 

Class I. Healthy gums, no caries, positive 30% 

Class 2. Healthy gums, carious teeth, positive.... 50% 

Class 3. Tartar and receding gums, positive 84% 

Class 4. Spongy and bleeding gums, positive 94% 

It will be observed that amoebas were found in every case, and 
that in inverse ratio to the health and cleanliness of the mouth. 

Commenting on this, the author says: "We can say nothing defi- 
nite yet as to the significance of the amoebas in these mouths. Find- 
ing these so often in apparently healthy mouths, and in such young 
children, does not agree with the statement of Bass and Johns and 
Barrett, that they are not found in healthy mouths." 

From among my own patients, I have to date (March 27th) se- 
lected 57 cases for examination, as follows: 

Pyorrhea (representing many types, and all stages, from the earli- 
est manifestations to hopeless cases), 47. Unclean mouths, but free 
from pyorrhea, 4. From around ill-fitting crowns, 4. Clean 
mouths (meaning those of which one sees only a few in a year, in 
perfect health), 2. 

From one to five smears were taken in each case. These were 
fixed with methyl alcohol, and sent to the Research Laboratory for 
examination, with the following results: 

Pyorrhea, 47 cases. Positive, 46; negative, 1*. 

Unclean mouths, 4 cases. Positive, 3; negative, 1. 

Clean mouths, 2 cases, both positive. 

From around crowns, 4 cases, all positive. 

From among the pyorrhea cases there were selected only 5 for 
emetine treatment. These showed an abundant discharge of pus, 
representing different types of disease. In one case, 28 teeth were 
involved; in another only 4, but all were cases in which the prog- 
nosis was favorable. In a word, there were no hopeless cases among 
them. None had less than six half grain doses of emetine, sub- 
cutaneously injected (y 2 grain daily), and two had more. At the 
conclusion of these injections, smears were again taken, never less 
than 3, and from all parts of the mouth. Numbers I, 19 and 46 
were still positive, numbers 5 and 60 were negative. Case No. 1, 
28 teeth involved, was then treated with a y 2 per cent solution of 
emetine flowed into the pockets daily for seven days, one Sunday 
intervening. Several smears were then taken ; all were positive. 
In none was there any improvement which could be observed after 
the most painstaking examination, except that in case 19, there was 
less inflammation of the gum around one especially bad tooth, pos- 
sibly due to the hemostatic action of the drug. This case had had 
six half grain doses of emetine, and several times the pockets were 
flooded as directed, yet two of the three smears were still positive. 

*A re-examination showed this to be positive. 



Treatment by Emetine. 435 

In none had the pus decreased. Four of the patients reported that 
their gums felt better, and No. 1 complained of an unpleasant feel- 
ing, "as though the gums were rubbed with alum," as she expressed 
it. How much of this was psychological I do not know. One 
patient was nauseated and vomited after the first injection of ^ 
grain. It is realized that these cases are too few to have of them- 
selves any evidential value. They form a part of an investigation 
begun long before the invitation to prepare this paper was received, 
and are reported here merely as corroborated of the findings of Le- 
Wald and Williams. 

It is too early to form any final conclusions regarding the role the 
endamoeba may play in the etiology of pyorrhea, or of the therapeutic 
value of emetine in its treatment. However, in view of the evidence 
already at hand, it may not be out of place to inquire into the present 
status of this so-called "wonderful discovery." 

In the light of this evidence there can be little doubt that the 
endamoeba is present in practically all mouths, contradicting the state- 
ment that they are found only in mouths in which there is pyorrhea 
(19). It is also probable that emetine is an amoebacide, but an un- 
certain one at the dosage advocated. Another characteristic of eme- 
tine and one of which no mention is made by those advocating its 
use in pyorrhea, is its hemostatic action (21). An interesting ques- 
tion which naturally suggests itself in this connection, is whether 
the improvement in the gums ascribed to its amoebicidal quality, may 
not be due to the fact that it is a hemostatic. The fact that cases 
with inflamed gums show improvement in this respect, and the state- 
ment of patients that their gums feel better, points to this as the ex- 
planation, as does the fact that those who were conscious of this im- 
provement while under treatment, after it was discontinued, state 
that the feeling of improvement gradually disappeared, and that they 
lapsed back to the condition which prevailed prior to treatment. If 
this be true (and there is at present no proof that it is not), its effect 
can only be transitory. On the other hand, if this improvement be 
due to the amoebacidal action of the drug, it must also be more or 
less evanescent, since it is practically impossible to permanently elim- 
inate the amoeba from the mouth. Whatever its action may be, 
there is at present no trustworthy evidence that it will cure pyorrhea. 
Until this can be done in a sufficient number of cases, and by a num- 
ber of investigators working independently, there can be no justifica- 
tion whatever for the claim that the endamoeba is the specific cause 
of pyorrhea. 



CHAPTER XXXV. 
BUSINESS SIDE OF PYORRHEA ALVEOLARIS. 

Dental offices have been flooded with all kinds of litera- 
ture calling attention to certain medicines and preparations 
which would "positively cure pyorrhea." Many of these 
preparations were accompanied by extracts from papers by 
some of the most prominent men in our profession, who 
claimed that pyorrhea was of constitutional origin, and that 
such and such a remedy was the only thing to use. Others 
gave their endorsement to the various local remedies which 
needed but to be applied several times for a complete cure. 
These preparations, having come so highly recommended 
by the profession, were tried out by the dentists, but the 
cases of pyorrhea on which they were used were not cured. 
The failure of all these remedies has made the general prac- 
titioner very skeptical as to the possibilities of curing pyor- 
rhea, and it is undoubtedly one reason why so few prac- 
titioners have undertaken to treat this disease. The busi- 
ness of treating pyorrhea was largely the sale of proprie- 
tary drug preparations. 

Another reason for lack of interest in pyorrhea treatment 
was the fact that the dentist did not try or was not able to 
secure from the patient the proper remuneration for the 
work. I have been unable to understand just why this is 
so, unless it is the failure on the part of the patient to realize 
the gravity of a beginning pyorrhea. The patient thinks 
that only his teeth need cleaning and that it is worth proba- 
bly $1.00 to do this. 

Within the last few years, a number of good men have 
specialized on either prophylaxis or pyorrhea work and 



Business Side of Pyorrhea. 



437 



the good work that has been done has forced on the pro- 
fession the recognition of the fact that pyorrhea work re- 
quires the greatest degree of skill and is probably the great- 
est service that we can render our patients. This work 
should command the largest fees that a dentist is able to 
command. It is a fact that patients of means and refine- 
ment are most appreciative and willing to pay large fees to 
the men who can save their teeth from pyorrhea. 



Daily Record < 
E> 


Card 
atk 


OF E 


R. J. B. WEST 










Hour. 


Name and Address 


Hour ent. 
Clinir 


Time L 
Chair 


Total 
Time 


Operation or 
Prof. Services 


Fee 


Debit 


Credit 


Cash 



























Fig. 122. A simple and effective card to be used by those who wish to 
employ the "charge for the time" system. 



One way is to charge for time, as in other dental work; 
this plan has serious drawbacks, and it seems to me that it 
is not the proper idea for surgical work. From the letter 
of a prominent California dentist, who does considerable 
work along this line, I give the following: 

"I think that 'so much per hour' proposition in a profes- 
sional charge, is not near so satisfactory as a lump sum; it 
has taken several years for me to fully appreciate that fact. 
I have frequently stood for the hour plan when patients 
requested a lump sum, and I have gotten the worst of it, 



438 Practical Pyorrhea Alveolaris. 

in as much as I could have obtained a larger fee had I men- 
tioned a stated sum, the same as a surgeon would do. In 
suggesting a fee now, I run through the mouth carefully; 
size up the worst or bad teeth; calculating in my mind the 
number at $15.00 per hour, and then the others in same pro- 
portion; and in that way get at a proposition of lump sum, 
always adding $25.00, $50.00 or $100.00, as the case may 
be, in case I anticipate the necessity of a compromise." 

My objection to the hour plan in pyorrhea work is that 
it seems to place our services on the wrong basis — emphasiz- 
ing the matter of time rather than the results obtained. 
Also, in case we are interrupted by being called to the phone 
or to give a few minutes time to someone else, our patient 
is probably wondering whether or not they are being charged 
for this time. 

A method used by a prominent dentist in New Orleans 
is to make a charge of $10.00 for each tooth, irrespective 
of time required for a complete cure. 

The system under which the author works is to give the 
patient an estimate of the entire cost of the operation and 
treatment before beginning the work. This plan having 
proved satisfactory and as I have been unable to secure 
minute data from others, I will give it in detail. 

The examination having been concluded, I anticipate the 
question, "Now, Doctor, how much is this going to cost 
me?" I at once fill out an estimate sheet; this sheet gives 
a diagram of the work to be done and the cost of same. 
There is also a blank space for terms, which is always filled 
in. At the bottom of this estimate is printed in red, an im- 
portant notice. (Fig. 123.) 

If I know the patient to be able to pay a good fee, to 
whom service is the main consideration, all that is neces- 
sary is to write out an estimate sheet and place it in an en- 
velope with the engagement card; this envelope is handed 
to the patient on his departure. 



Business Side of Pyorrhea. 439 

A cheap and efficient means of getting up this estimate 
is to use the one dollar dental outfit published by the John 
C. Moore corporation, of Rochester, N. Y., and have a 
local printer insert at the bottom of page the above notice. 
A heavy carbon sheet is used between two sheets. The copy 
is torn out and given to the patient; the original is kept in 
a loose leaf binder. 



PRESERVE THIS ESTIMATE 

The above is only an approximate estimate of services 
the exact value of which can only be determined after the 
operations are completed. 

The charges therefore will not be based upon this esti- 
mate, but entirely upon what is done. Any change in work 
named above or additional operations will be charged at 
our regular fee. 

We do not guarantee any operations. 



Fig. 123. The estimate book is printed in dublicate with carbon at- 
tached. At the bottom of each sheet is printed the above matter in 
red ink. 



It has been found by all men who do operative work in 
either dentistry or general surgery that a deposit in advance 
is a most satisfactory basis upon which to work. I have 
adopted it as an absolute rule which is explained to the pa- 
tients, and, since I allow no exceptions to this rule, no one 
raises any objection. If questioned at all, I tell them that 
it is for their own protection as well as mine; that I know 
they are as good as gold, but that I want their teeth saved, 
and if I start into it that I am going to do the very best 
I can towards this end and that I know if they have from 
$50.00 to $100.00 paid in advance they are going to keep 
coming until the work is done. If they did not do this, the 
first day after their mouths get comfortable, there would 



440 Practical Pyorrhea Alveolaris. 

be danger of their not coming back for regular treatment. 
If they have made the deposit, as I have said, they will keep 
all appointments as long as you wish. 

Sometimes a patient, whom you know to be all right, 
wishes services, but at the time finds it inconvenient to make 
a cash payment or to pay within a reasonable length of 
time. Credits along this line used to be unsatisfactory; 
at the time of treatment, the results seemed all that I could 
wish, but such patients would neglect their mouths until oral 
sepsis had again set in, and would declare that they had 
received no benefit and refuse to pay. This difficulty has 
now been solved satisfactorily in my practice by a special 
promissory note. If they are unable to make a cash pay- 
ment, then I tell them that if they will give me notes and 
pay eight per cent, for deferred payments, I am perfectly 
willing to settle the matter up in this way. (Fig. 124.) 

This note is good for any kind of dental operations, es- 
pecially pyorrhea. If it is not met in due time and the pa- 
tient for any reason refuses to pay same, instead of being 
humiliated by having to argue the case in court, this note 
cuts off debate in justice court and a judgment is immediately 
given to the dentist. It is a bad proposition to work for 
people who can not pay, but this note is the best solution 
of the problem that I have been able to obtain. 

If I were going to have any kind of operation performed, 
I certainly would want to know just exactly what it is going 
to cost me, and I believe in treating the patients with that 
fairness which I would ask under the same circumstances. 

There was a difficulty which used to present itself to me 
before I started to keeping copies of the estimates. The 
patients, after an examination, were told about what the 
work would cost them. They did not have the work done 
at that time, but would come in again, probably, at the end 
of three or four months. After another examination I 



Business Side of Pyorrhea. 



441 






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442 Practical Pyorrhea Alveolaris. 

would again tell them what the charges would be. The 
patient, having forgotten, would say that I had promised 
to do it $20.00 or $30.00 cheaper at the time I made the 
first examination. Now, with my present system, I can re- 
fer to my files and can convince him immediately of his mis- 
take. Previously, when other work was done in addition 
to the work estimated on, the patient, when settling the bill, 
could not be made to understand that more work had been 
done, and they would not think it right that any additions 
should be made to the estimate as first named. My system 
settles this question and there is never any objection, as 
the estimate suggests and puts the patients on notice that 
other work may be discovered and will be charged for. 

For instance, in making a bridge abutment, if the tooth 
that I hoped to use as an abutment could not be saved, 
then I would have to drop back and make the bridge more 
extensive; they often thought that the charge should be 
the same. 

The greatest difficulty that I have had is with the ques- 
tion, "Now, doctor, do you guarantee the operation?" I 
became so tired of hearing this that I inserted at the bot- 
tom of the estimate sheet, "We do not guarantee any opera- 
tions." This immediately settles all questions, and if the 
patient is not willing to trust himself to my reputation and 
skill, he is at liberty to go somewhere where a "cure is 
guaranteed." 

This is well answered by Dr. R. G. Hutchinson, Jr., who 
says: 

"A cure does not guarantee immunity and a true recur- 
rence in no way invalidates a cure." 

I find that the terms "scaling the teeth," "removing tar- 
tar," and "treatment of the gums," do not impress the pa- 
tients with the seriousness of pyorrhea treatment. There 
is a fad among people for "operations," and if the dentist 
calls it by this name, which is really the proper term, our 



Business Side of Pyorrhea. 443 

patients like it much better and are willing to pay satisfac- 
tory fees for it. I find it better to do as much of the work 
on the first day of the engagement as possible — enough to 
at least verify myself in calling it an "operation." In addi- 
tion to this business reason, I get better results as described 
in the chapter on "Treatment." 

I do not care to do more than two or three pyorrhea op- 
erations in one day, and if I finish one-half the work for 
each patient, giving each two to three hours, I feel that I 
have done enough. 

In pyorrhea work the use of a proper system in our busi- 
ness dealings with patients should not detract from our pro- 
fessional dignity and the returns will be such that we can 
have more vacations, more recreation, and more time with 
our families. 



CHAPTER XXXVI. 

THE MEDICAL AND SURGICAL ASPECT OF 
ORAL HYGIENE AND PYORRHEA. 

VIEWS OF PROMINENT MEDICAL MEN. SUGGESTIONS TO 

PHYSICIANS AS TO CARE OF THE MOUTH IN SICKNESS. 
ORAL PREPARATION FOR SURGICAL WORK. 

VIEWS OF PROMINENT MEDICAL MEN. 

Dr. C. H. Mayo recently read a paper (Jan. 31, 1913) 
in Chicago, in which he made the following statement: "It 
is evident that the next great step in medical progress in 
line of preventive medicine should be made by the dentists." 

The facts about oral hygiene, oral sepsis and pyorrhea 
alveolaris, are of vast importance to the physician, as well 
as to the dentist. In many cases they are of vital impor- 
tance and yet comparatively little has been written on the 
subject. 

We have under observation cases treated from ten to 
fifteen years ago which before treatment, had been advised 
that extraction was the only thing that would relieve them; 
but the patients have never lost their teeth. Some of these 
cases were in such a serious condition that a continued neg- 
lect of the mouth condition would probably have resulted 
in death from septicaemia. 

An interesting case in the author's experience was that 
of a woman who had suffered for several months with very 
severe pains in the head; her physicians had been unable 
to afford any relief. The surgeons had advised that an 
operation be performed on the trifacial nerve. Being 
called in as a consultant, I found a severe case of pyorrhea 



Views of Medical Men. 445 

and by treating this for a few days was able to give the 
patient almost complete relief from pain. 

Many cases of interest like the above are contained in 
my records, but I do not feel that there is room for them 
in a work of this kind. 

Nor will space here allow the insertions of full case rec- 
ords from other specialists, but dental and medical litera- 
ture is full of them. That the beginner in this work may 
know what great benefit may be given humanity, mention 
is made of a few results, selected at random from authori- 
tative reported cases. 

Cases of arthritis deformans, due to pyorrhea, have been 
greatly benefited by dental attention. Ulcer of the stom- 
ach, caused by pyorrhea, cured by dental treatment. Many 
cases of chronic dyspepsia have yielded promptly. Patients 
who had albumen and casts inside of two weeks have been 
returned to normal conditions. 

Dr. Upson has reported that pyorrhea has caused many 
cases of insanity and that a large number of such cases are 
restored by curing the pyorrhea. 

Dr. B. Craig, chief of clinic Neurological Institute of 
New York, in a paper before the American Medical Asso- 
ciation, made the following statement: 

"For a considerable period it has been observed that a 
bad condition of the teeth may be responsible for adjacent 
disorders, such as otalgia and tic douloureux, but the ob- 
servation that stubborn neuritis of the sciatic or other nerve 
trunk or of the brachial plexus sometimes disappears after 
cleaning out the alveolar disease, is of comparatively recent 
date. The continual swallowing and absorption of pus is 
undoubtedly the cause of disorders of digestion, headache 
and finally an anemic condition almost cachectic. This de- 
pleted, exhausted state may often be associated with a mel- 
ancholic state. It seems a far cry from mouth infection 
to mental disease, but when one witnesses profound depres- 



446 Practical Pyorrhea Alveolaris. 

sion clear up following the drainage of several alveolar 
pus-pockets, one is persuaded that the chronic intoxication, 
the result of absorption from the pent-up infectious proc- 
ess, was an etiologic factor." 

Dyspepsia, flatulence, and gastric ulcer, together with all 
their varied symptoms, are often caused by the large num- 
bers of bacteria and their products which are constantly 
swallowed. 

The tonsils, bronchi, and even the living membrane of 
the arteries and heart may become infected from diseased 
gums. Many cases of eye and ear complications are re- 
lieved by curing the case of pyorrhea. 

Patients will often want to know how it is that certain 
of their friends have had pyorrhea for twenty-five years, 
and seem to get along without any inconvenience. In an- 
swer we may assure them that the immunity is more in ap- 
pearance than real, and that at any time this immunity 
may suddenly give way, and any of the mentioned compli- 
cations arise too late for a cure. 

Dr. Julian Zilz, of Vienna, reports some interesting sta- 
tistics about the frequency of the association of diabetes with 
pyorrhea alveolaris. Seventy-one of the cases examined 
had pyorrhea alveolaris. Nearly half of these have a his- 
tory of gum trouble before the diabetes. Only in a small 
number did the pyorrhea follow the incipiency of the dia- 
betes. In all these cases, the saliva showed acid reaction. 
This report shows the necessity of making^the sugar test 
with a specimen of the patient's urine. 

Dr. M. M. Bettman suggests to the author to "emphasize 
the constitutional effects of a neglected pyorrheal condition 
a little more, especially, in the light of the findings of Dr. 
Rosenow, of Rush Medical College. I have noticed nu- 
merous times clinically what he has proven experimentally. 
Only the other day a patient returned for prophylactic 
treatment whom I had treated about six months before for 
an aggravated pyorrheal condition and I was very much 



Views of Medical Men. 447 

surprised at his improved general appearance. At his first 
visit he informed me that he had lost weight from 215 to 
140 pounds. I cured his pyorrhea at that time and without 
treatment of any kind except for the pyorrhea; he has grad- 
ually gained until he now weighs 205 pounds. This is, I 
think, a very good example of the general effects of the ab- 
sorption of pus from a pyorrheal mouth." 

Dr. H. A. Goldberg reports an interesting series of cases 
from the Hospital for Deformities and Joint Diseases, of 
New York. These cases presented symptoms of rheuma- 
tism, arthritis, pain in joints, or high temperature. All of 
them had pyorrhea mouths, and when these were cleaned 
up, the above-mentioned general symptoms disappeared. His 
conclusion is to "call the attention of physicians and den- 
tists to the frequency of constitutional infection from septic 
pyorrhea alveolaris, resulting in joint involvement, which, 
no doubt, is often wrongly diagnosed as rheumatism and 
treated as such, without result, while if the cause is recog- 
nized and the source of infection in the teeth treated, a 
speedy and successful result is obtained." 

From these examples we would not have our medical 
friends think that we are claiming the whole of pathology 
is caused by pyorrhea, or that its treatment is a "cure all," 
but we will admit that it seems each month to be tending 
that way, due to the recent startling discoveries, all of 
which goes to show the intimate relationship which could 
exist between the two professions. 

It should be the aim of all well-informed dentists to in- 
struct all their patients who are nurses and physicians, as 
to the importance of this neglected field of their work. Such 
instruction, if put into practice, would undoubtedly help any 
physician not only to give comfort to the sick, but a quicker 
restoration, to health. 

Every dentist is familiar with the great amount of decay 
and oral sepsis frequently seen in convalescent patients who, 



448 Practical Pyorrhea Alveolaris. 

previous to their illness, possessed a normal mouth. On 
inquiry, we sometimes learn that during sickness these 
mouths received the usual care as given in hospitals. 

In other cases when a person becomes sick he often neg- 
lects the little attention formerly given the mouth. Vigor- 
ous chewing is dispensed with, exercise of the muscles of 
mastication ceases, aeration of the mouth is lessened, with 
the result that all self-cleansing processes are diminished 
and the saliva becomes thick and ropy. The mouths of the 
sick are often a hot bed of filth and disease, as indicated 
by the foul breath, and are a most prolific breeding place 
for the bacteria of pneumonia, diphtheria, tuberculosis and 
other diseases. 

SUGGESTIONS TO PHYSICIANS AS TO CARE OF MOUTH 

IN SICKNESS. 

Physicians should be told by the dentists that conditions 
such as the above can be changed for the better. The time 
will come when the physician will realize the necessity of 
giving directions for the care of the mouth as a routine 
procedure in every case of sickness. At the present time 
the nurse is supposed to attend to the patient's mouth, but 
most of them are woefully ignorant on the subject and the 
patient suffers thereby. 

When a physician refers a patient under treatment to a 
dentist, the latter should not be content to limit his work 
to fillings, crowns and bridges, but should recognize any 
diseased condition of the gums and should report the find- 
ings. This kind of service will often prove of vast impor- 
tance in the etiology, diagnosis and treatment of systemic 
disturbances. The discovery of oral sepsis in a patient's 
mouth is of far more importance to the patient, the dentist 
and the physician than the filling of teeth. This view of 
the matter was expressed by Dr. William Hunter, physician 
and lecturer on pathology, to the Charing Cross Hospital, 



Suggestions to Physicians. 449 

of London, in his famous classic upon the subject of "Oral 

Sepsis." 

"One would think poorly of a surgeon or doctor who declined to 
take the responsibility of treating a follicular (that is, a 'septic') 
tonsilitis, but insisted on handing over the case to a throat specialist, 
or who allowed a patient to suck continuously a number of septic sores 
on his finger. I think no less poorly of any doctor or surgeon who 
declines to make himself responsible for the treatment of much of the 
oral sepsis presented by many of his cases. For this is what patients 
are constantly doing. Wherein consists the pathological difference 
between a follicular tonsilitis and a foul, septic, suppurating condition 
of the gums, with deposition of calcareous 'crusts and scabs' (so- 
called tartar) covering and hiding septic wounds and ulcers, loaded, 
as miscroscopic examination shows, with staphylococci and strepto- 
cocci? None whatever, except that the latter is exceedinely common 
and the tonsilitis is comparatively rare. The pathological condition 
in both is the same ; namely, sepsis. Moreover, it is a sepsis as easily 
recognized and much of it as easily removed in the case of the one as 
in that of the other, and the more urgently requiring to be removed, 
since it is more important as a potential disease factor than any other 
source of sepsis in the body 

"The chief feature of this particular oral sepsis is that the whole of 
it is swallowed or absorbed into the lymphatics and blood. Unlike the 
sepsis of open w r ounds on the outside of the body, none of it is got rid 
of by free discharge on the surface. The effects of it, therefore, fall 
in the first place upon the whole of the alimentary tract from the 
tonsils downward. These effects include every degree and variety of 
tonsilitis and pharyngitis ; of gastric trouble, from functional dyspep- 
sia up to gastritis and gastric ulcer, and of every degree and variety 
of enteritis and colitis and troubles in adjacent parts, e. g., appendicitis. 
The effects fall in the second place upon the glands (adenitis) ; on the 
blood (septic anemia, purpura, fever, septicemia) ; on the joints (ar- 
thritis) ; on the kidneys (nephritis), and on the nervous system. . . . 

"The following cases show to what extent oral sepsis complicates 
specific fevers, such as scarlet fever, typhoid, diphtheria, and the strik- 
ing benefits to be got from its removal. 

"In 648 cases of scarlet fever admitted to the London Fever Hos- 
pital under my care in the four years 1904-7, the incidence of oral 
sepsis, carefullv noted by myself, varied from 25 per cent, to 43 per 
cent. The effect of oral antisepsis (the removal, as far as possible, 
immediately on admission, of every trace of oral sepsis around the 
patient's teeth and gums, by daily swabbing with 1-40 carbolic acid 
solution) throughout the earlier part of the disease was very striking. 
The chief complications of the disease were reduced as follows: The 
incidence of secondary adenitis was reduced from 6 per cent, in 1 904 



450 Practical Pyorrhea Alveolaris. 

to 3.3 per cent, in 1906 and 1.8 in 1907 ; of cellulitis of the neck from 
5.2 per cent, in 1904 to 2.8 per cent, in 1906 and nil in 1907 ; of glan- 
dular suppuration from 1.7 per cent, in 1904 to 0.5 in 1906 and nil in 
1907. The striking improvement was due to the increasing care 
taken by myself and by my residents and nurses under my instructions. 
In only one or two cases out of the whole series were any teeth ex- 
tracted. 

"What are the general principles of the treatment applicable to 
medical sepsis? The first and most important is curiosity about and 
careful observation of the actual character and degree of the septic 
foci present in the mouth (naso-pharynx or elsewhere) in every case 
of medical disease. This observation can not be made by a cursory 
glance into the mouth and a general conclusion to the effect that the 
'teeth are fairly good,' or the mouth 'fairly clean,' or that the mouth 
'requires to be seen to.' If you look closely into the mouth of your 
patients and note what you see, you will observe every degree and 
variety of septic ulceration; every degree of tartar deposit, as a great 
effect of these septic inflammation and ulceration ; every degree of sup- 
purative inflammation of the gums; every degree and effect of septic 
periostitis and periodonitis, with formation of pockets and loosening 
of teeth; every degree and effect of septic osteitis — e. g., rarefying 
osteitis, causing recession of the bone socket of formative osteitis, caus- 
ing thickening of alveolus ; every degree and variety of septic caries and 
necrosis of the teeth, and as a result of all these conditions, singly or 
combined ; every degree and variety of septic stomatitis, simple, ulcer- 
ative, gangrenous. You will see all this in infinitely less time than it 
takes to examine a specimen of the gastric contents, or of the feces, or 
of the urine, or of the sputum ; in far less time and with far less labor 
than it will take you to examine the nose, or the naso-pharynx or the 
larynx; in far less time than it takes you to examine the heart or the 
liver, or, indeed, any other organ of the body. In particular cases you 
will observe that all these septic conditions are produced or intensely 
aggravated by toothplates covering necrossed roots; by amalgam and 
gold fillings which have become septic ; by porcelain crowns with gold 
collars; which, however good to begin with, are never really aseptic, 
and are liable to become extremely septic. All these you can observe 
in a few minutes, if you look for them — in less time almost than it 
takes to mention them." 

Several other interesting and authoritative quotations are 
appended: 

"There is little doubt in my mind that bad mouth-hygiene favors 
the development of pneumonia by paving the way for pneumococcus 
sinusitis, which, as pointed out, frequently antedates a true pneumo- 
coccus infection. Anv inflammation of the nasal sinuses should there- 



Suggestions to Physicians. 451 

fore be promptly treated." — Harvey G. Beck, M. D. (Interstate Med. 
Jour.) 

"Bad teeth are an enormous factor in the development of catarrhs. 
Many a chronic catarrh is kept up for this reason alone." — John B. 
Huber, M. D. (New York Med. Jour.) 

"The important part of scarlet fever is a focus of infection located 
either in the nose, in the mouth, or in the nasal pharynx, and from 
these sources the poisons are circulated through the body. Thus the 
poisons are but giving expression to themselves in the eruption that has 
been held heretofore to be of such consequence. 

"The importance of diphtheria I am sure is fully understood, but 
the enlargements of the glands of the neck, of the nose, of the tonsils, 
and of the pharynx are due to absorption somewhere in the nose or 
in the mouth, a very large percentage of which takes place through 
cavities in the teeth or down the sides of unclean teeth. Not only 
that, but we are constantly confronted with instances like this, a child 
has been in a diphtheria hospital and has remained there until it 
seemed safe for the child to go home. Then the child has gone home, 
and there has followed an infection with diphtheria in that home. 
What is the logical explanation? The logical explanation is that in 
some hidden recess, somewhere in that child, there was a focus of 
hidden bacteria; and that in all human probability a large percentage, 
it not an overshadowing percentage, of those infections are either in 
the tooth cavities or somewhere in close connection with the tooth 
cavities."— Dr. W. A. Evans, M. D. 

In typhoid fever and allied conditions, the mouth is a 
veritable hotbed of the very infection we most want to 
control. Just think of your patient having 28 to 30 square 
inches of infected surface feeding the diseased intestine and 
no attention being given it. I have proven to my own 
satisfaction that all cases of fever are more easily cured and 
have fewer complications when the mouth is maintained in 
a hygienic condition, before and during illness. 

Frankel, Wachselbaum, and Miller agree that the most 
frequent excitant cause of pneumonia is infection from the 
mouth. Miller says, "The oral cavity serves as a gather- 
ing point for this infection, which from time to time is car- 
ried into the lungs with the air, until at last at some weak 
point, or as the result of some inflammatory action of the 
lungs, through which the power of resistance is impaired, 
it obtains a foothold in the lungs. For this reason, there- 



452 Practical Pyorrhea Alveolaris. 

fore, and very many others, the neglected oral cavity offers 
a dangerous cover of infection, which by no means received 
the attention it deserves." 

Numerous investigators have pointed at the tonsil as a 
possible point of entry of rheumatoid infection. Billings 
reports cases of multiple arthritis cured by enucleation of 
the tonsils; also, several cases of arthritis deformans and 
parenchymatous nephritis due to infection of streptococci 
planted in pyorrheal pockets. 

Dr. A. H. Stevenson, in a letter writes me : 

"It is generally believed that the bacteria of the common 
infections, viz. : diphtheria, pneumonia, scarlet fever, and 
typhoid invaded the body through the air passages, but 
Jonathan Wright and other investigators find that the tur- 
binate bones of the nose, and the ciliated epithelium cover- 
ing the mucous membrane of the nose, act as sieves or 
screens, preventing most bacteria from entering the throat, 
bronchi, or lungs by this route. The mouth, therefore, 
must be the chief means of these infections reaching the 
lungs or stomach. The function of the stomach may be 
impaired by this bacterial invasion. The hydrochloric acid, 
Nature's great germicide, is able to overcome the bacterial 
attack that occurs with the normal acquiring of food, but 
the constant ingestion of pyogenic material from a septic 
mouth seriously interferes with, and may prevent the nor- 
mal secretion of the hydrochloric acid. This may result in 
the subsequent disturbance of the process of digestion. 

"With a wound on the surface of the body, the bacteria 
and their toxins are eliminated with the surface discharge, 
but where there is a lesion of the mouth, an alveola abscess, 
for example, the septic material is swallowed or disposed 
of by the lymphatics or the blood. If the resistance of 
the tissues is high, and the individual in excellent health, 
this daily toxic dose may be taken care of, but the effect 
falls upon the entire alimentary tract. Dr. E. C. Kirk calls 



Suggestions to Physicians. 453 

this the 'toxic habit,' and like all offensive habits, it be- 
comes apparent to others before it does to the afflicted. 
Other results showing the results of oral sepsis could be 
continued 'ad infinitum.' The increase of papers on this sub- 
ject appearing in the medical journals is encouraging." 

In my experience in hospital work I have found that the 
majority of patients do not receive treatment for mouth 
conditions. The time-honored method of using a strip of 
gauze on the finger is better than nothing, but on account 
of the shape of the teeth a considerable amount of infectious 
debris is packed between the teeth and into the depressions 
around the tongue. 

If the mouth is first examined in office practice and found 
to need attention, the physician should send the patient to 
that dentist whom he has reason to know will put it in a 
hygienic condition, and instruct the patient in oral hygiene. 
If the patient is confined to bed, we know from experi- 
ence that those who ordinarily brush the teeth often neglect 
this duty. 

Whose duty is it to brush the teeth of the sick patient? 
The physician should be able to demonstrate to some mem- 
ber of the family, or if a nurse be in attendance, instruct 
her how to use the brush and mouth wash. I have seldom 
seen a nurse who knew how to brush her own teeth; there- 
fore I give her implicit instructions as to the proper man- 
ner of brushing not only the teeth, but the whole mouth, 
including the tongue. I hope the day is not far distant 
when every training school for nurses will incorporate a 
few lectures on this subject in their course. 

The teeth of a bed-ridden patient, even if in normal con- 
dition, should be washed properly several times each day 
and rinsed every few hours with some cleansing solution. 
The most serious consequence of tooth decay, following 
sickness, is due to the infection between the teeth. The use 
of gauze will not remove the material. The tooth brush is 



454 Practical Pyorrhea Alveolaris. 

a necessity. It goes between teeth, it removes the accumu- 
lation as gauze can not. The texture of the brush should 
be of the softest grade obtainable. Some good tooth paste 
should be used in preference to a powder; a powder must 
be changed into a paste in the mouth before it becomes 
efficient; before it changes to a paste, some of it gets lodged 
between the teeth, where it stays; some of it is apt to be in- 
haled, irritating the throat and lungs. A paste does the 
work quicker and has the advantage that it generally con- 
tains some antiseptic. This must be followed by a mouth 
wash, and for this purpose lime water or salt water will 
answer, but a prescription of chlorate of potash, with a few 
drops of phenol is efficient for the purpose of cleansing and 
disinfecting. 

Even though a patient can not raise his head, oral clean- 
liness must not be neglected. Here it is good practice to 
irrigate the teeth and mouth by turning the head to one side, 
having the patient draw the fluid into the mouth through a 
long glass tube, and instructing him to close the lips and 
force the fluid between the interspaces of the teeth, flushing 
the whole cavity and the throat. In other cases, the ordi- 
nary long-spout feeding-cup can be used without the patient 
moving the head. By closing the lips over the spout, this 
cleansing liquid can be drawn into the mouth and later emp- 
tied back into the cup just as it was received. In other 
cases, it is advisable to use the fountain syringe and flush out 
the mouth just as you would any other infectious cavity. 
Use a nozzle that will give a fine stream and don't be afraid 
to use plenty of pressure. 

If oral sepsis is present, in addition to the cleansing it is 
necessary to make a topical application of some formulae as 
Skinner's Disclosing Solution, Buckley's Pyorrhea Astring- 
ent, or AA Pyorrhea Treatment (pages 176, 391, 404), or 
some similar preparation containing iodine, which drug 
alone will penetrate in the mouth. 



Preparation for Surgical Work. 455 

Proper attention to the mouths of the sick and before 
operations by the surgeon will undoubtedly be productive 
of comfort to the patient preventing infections and will 
prove one of the greatest aids that can be used to restore 
the health of the patient. 

ORAL PREPARATION FOR SURGICAL WORK. 

If there is one place where the dentist can be of great 
help to the general surgeon, it is in the preparation of the 
mouth before the anesthetic is given for all operations. The 
surgeon wears a mask, and is all attention to every detail, 
but often neglects a great source of infection and danger — 
the mouth. Dentists should urge the strengthening of this 
chain in aseptic surgery. No doubt many of the post-opera- 
tive pneumonias are due to infection from septic mouths con- 
taining pneumococci. In this regard we must teach our 
physician friends not to rely on rinsing the patient's mouth 
with the ordinary solutions used as mouth washes. Un- 
doubtedly, it would be safer for the patients if their mouths 
could be cleaned by a staff hospital dentist, and the day is 
not far distant when just as much attention will be given the 
mouth in hospital wards as is now accorded examinations 
of the heart, lungs or kidneys. 

The above should serve to give a glimpse into the many 
important and practical relations between medicine and den- 
tistry. The solution of such problems requires knowledge 
on the part of the dentist and full recognition of the impor- 
tance of mouth hygiene on the part of the medical profes- 
sion. 



INDEX OF AUTHORS 



PAGE. 

Adair, R. B. . . 153, 344, 403 

Albray, R. A 59 

Anderson, C. G 6 

Atkinson, C. B 285 

Barrett, M. T. . . . 295, 432 

Bass, C. C 295, 432 

Beck, H. G 451 

Beetman, M. M. . . . 372, 44G 

Belcher, W. W 31 

Billings, P 452 

Black, Arthur D. . 154, 229, 231 
Black, G. V. 

30, 273, 280, 285, 304, 319 

Bogue 27 

Brown, C. P 285 

Brown 304 

Carmichael, J. P 218 

Clapp, G. W 127 

Cook 210 

Corley, J. P 67 

Craig, B 445 

DeFord, W. H 258 

Deichmiller, Conrad . . . 398 

DeLima, Agnes .... 32 

Dismukes, J. F 125 

Dodge, H. N 122 

Dunlap, Wm. F 379 

Ebersole, W. G. . . . 149, 261 
Evans, W. A 451 

Filder, Prof 374 

Fisher, Prof 149 

Fletcher, Horace .... 4 
Fletcher, M. H. 

154, 185, 280, 350, 362 
Fones, A. C. 

117, 158, 171, 185, 187, 225, 259 

Gallie, Donald M 102 

Gartrell 345 

Gearhart, CM 274 

Goodby, K. W 320 

Goble, L. S 211 

Goldberg, H. A 447 

Good, Robt. . 349, 351, 372, 425 

Gulick, L. H 36 

Hamm, A. C 345 

Harris, G. B 429 

Hoag, Flora N 275 



PAGE. 

Harrell 214 

Harper 190 

Hart, C. E 261 

Hartzell, T. B. 

290, 299, 317, 343, 345, 391 

Hayden, Gillette . . 236, 210 

Head, Joseph . . . 243, 374 

Hoff, N. S. . 124, 125, 146, 274 

Hoffman, H. F 140 

Holmes, H. W 33 

Howard, C. C 27 

Howe, P. R 304 

Huber, J. B 451 

Hunt, Geo. Edwin ... 93 

Hunter, Wm 448 

Hutchinson, R. G. 

288, 290, 336, 372, 442 

Hutchinson, Woods ... 87 

Hyatt, T. P. ... 6, 79, 260 

James, A. F 286, 346 

Jenkins, N. S 155 

Johnson, C. N 212 

Jones, C. W 345 

Jungman, J. W. 213, 215, 217, 424 

Kells, C. Edmund 

151, 168, 171, 195, 224 

Kelley, Henry A. 207, 215, 234, 238 

Kelsey 374 

Kirk, E. C. . 171, 262, 343, 452 

Knopf, S. A. . . 146, 148, 149 

LeRoy, L. C 365 

LeWald, L. F 299 

Lubowski 147 

Lundy, E. A 381 

Marshall, J. S 34 

Mayo, C. H 444 

Meisburger, Louis . . . 371 

Merritt, A. H. . . . 260, 299, 

326, 327, 337, 377, 431, 433 

Miller, W. D 280 

Mitchell, L. G 107 

McCall, Jno. O. . . . 229, 299 
McDonough, A. J. ... 281 

Niles, Geo. M 169 

Nodine, Alonzo M. . 25, 262, 328 
Noguchi 294 

Oakman 139 



458 



Index of Authors. 



PAGE. 

Pague, F. C 313 

Patterson, J. D 359 

Peck, A. E 158, 335 

Pickerill 201, 246 

Pierce, C. N. . . Y . .285 
Potter 27 

Rehwinkel 280 

Reed, G. H 387 

Rhein, M. L. 

189, 191, 193, 280, 28G 
Riggs, John M. . . . 280, 342 
Rosenberger, Prof. . . 293, 299 
Rosenow, E. C. . 293, 294, 446 

Sarrazin, J. J. 150, 339, 351, 360 

Scip, H. S 265 

Sellers, A. M 125 

Skinner, F. H. 

176, 215, 265, 354, 389 

Smith, D. D. ... 150, 185, 

189, 193, 212, 286, 338, 371, 387 

Smith, Julian 393 

Spalding, E. B 187 



PAGE. 

Spalding, Grace R. 167, 235, 237 
Stevenson, A. H. . . . 54, 452 

Stewart, F. E 293 

Stillman, Paul R 161 

Talbot, E. S. . . 280, 299, 381 

Taylor, L. C. . . 188, 190, 220 

Thorpe, B. Lee .... 187 

Towner, J. D. . . . 235, 349 

Upson 445 

Van Cott 85 

Weidmann 147 

West, J. B 299-382 

White, W. A 103 

Woodbury 24, 25 

Younger, W. J. 

286, 325, 343, 349, 372 

Zarbaugh, L. L 62 

Zentler, Arthur . . . . 280 
Zilz, J 446 



INDEX 



A 

AA Pyorrhea Treatment 403, 415 
Abrasives for Cleaning 178, 180 
Abscess, Alveolar .... 320 
Abscess, Treatment of Pulp 321 
Treatment of Pyorrheal 421 
Absorption of Roots of Per- 
manent Teeth ... 317 

Acid, Lactic 372 

Acid Treatment of Pyorrhea 372 
Accidental Injuries to the 

Gingivae 291 

Agglutinin of Salivary Cal- 
culus 304 

Alveolar Abscess .... 320 

Alveolar Process . . 312, 317 
As Transitory Structure 

in Pyorrhea ... 312 

Amebae, in Pyorrhea . . . 295 

Amputation of Roots . . 417 

Anesthesia for Pyorrhea . 393 

Antiseptic Solution . . . 391 

Applications for Treatment 405 

Army and Oral Hygiene . 8 

Artificial Teeth in Pyorrhea 340 

Astringent, Pyorrhea . . 391 
Auto-intoxication in Pyorrhea 409 

Autogenous Vaccines . . . 429 



B 



G6 
293 
169 
374 
368, 415 
340 



127 
169 



Bacteriology .... 

Bacteriology of Pyorrhea 

Bad Breath .... 

Bifluoride of Ammonium 

Bifurcation Treatment 

Blood Pressure 

Boston, Infirmary 

Breath, Bad .... 

Bridgeport, Tooth Brush 
Drill 

Bridgeport Clinic .... 118 

Bridge Work in Pyorrhea . 422 

Brush, Care of . . . 78, 162 
Directions for . . . 158 
Shape of . 47, 150, 154, 158 

Brushing the Teeth 

46, 76, 150, 151, 153, 156, 161 

Business Side of Pyorrhea . 437 



Calculus, Serumal 
Salivary 



303 
304 



Carious Bone 313 

Children's Teeth, Oral Hy- 
giene 19 

Care of 196 

Cincinnati, School Forms . 135 

Cleaning the Field of Opera- 
tion 354 

Cleaning the Teeth ... 173 

Abrasive Mixture Used in 180 

Instruments Used in . 177 

Skill Required for . . 174 

Time for 175 

Cleveland, School Work in, 

102, 130 

Clinics, Cincinnati . . . 130 

Cleveland 130 

Denver 139 

Detroit .... 125, 137 

Morristown .... 121 

Place for 123 

Rochester 130 

St. Augustine . . . 125 

Composition of Salivary Cal- 
culus 301 



Decay, Tooth 48 

Dental Clinic, Cincinnati . 133 

Cleveland 130 

Denver 140 

Detroit . . . 125, 139 

Morristown .... 121 

Place for 123 

Rochester 130 

St. Augustine . . . 125 
Dental Dispensary, see Dis- 
pensary. 

Dental Floss Silk . . 166, 178 

Dental Hygienists . . . 117 

Dental Infirmary, Forsyth . 127 

Dental Nurse 259 

Legal Status of . . . 267 

Dentition 38 

Denver, School Forms . . 141 

Deposits on Teeth ... 301 

Removal of ... . 177 

Detroit Clinics . . . 125, 139 

Direction Cards .... 151 

Disclosing Solution . . . 176 

Dispensaries, Dental . . . 121 

Dispensaries, Industrial . 5 

Armstrong Cork Co. . 6 

Cotton Mills .... 7 



460 



Index 



Dispensaries, Industrial — Cont'd. 
Heinz Preserving Co. . 6 
Lord & Taylor ... 6 
Larken Soap Factory . 6 
Match Factories ... 5 

Morris & Co 5 

Metropolitan Life Insur- 
ance Co 6 

Wannamaker .... 6 
Dressings in Pyorrhea . . 402 
Drugs used in Pyorrhea . . 371 



Emetine, Treatment in 

Pyorrhea . . . 296, 432 
Enamel, Tooth ... 48, 243 
Endameba Buccalis . . . 296 
Ethyl Borate Treatment . 379 
Examination of the Mouth, 

Card for ... 384, 390 
Instrument for . . . 132 
Record of . . . 384, 390 



Female Assistant .... 250 

Fissures, Treatment of . . 220 

Floss Silk .... 166, 178 

Food Mastication . 28, 83, 202 

Foods, Effect on Teeth . 42, 198 

Forsyth Infirmary . . . 127 

G 

Gingivitis Due to Deposits of 

Serumal Calculus . . 303 

Gingivitis, Caused by Injur- 
ies 291 

Tooth-Brush Injuries . 291 

Girard College, Oral Hygiene 

in 12 

Grooves, Treatment of . . 220 

Gums, 

Congestion .... 306 

Recession 306 

Resection 309 

Tumefaction .... 308 



Hygienist, The Dental 



Implantation 

Industrial Dispensary 
Armstrong Cork Co 
Lord & Taylor . 
Match Factory 
Morris & Co. . 
Wannamaker . 



117 



413 
5 
6 
6 
5 
5 
6 



Infant's Mouth, Method of 

Cleaning 14 

Inspection School . . . 101 

Forms Used for . . . 130 

Importance of ... 114 

Instrumentation in Pyorrhea 353 

Instruments .... 177, 396 

For Cleaning Teeth . . 177 

For Hand Polishing . 212 

Good- Younger Set . . 177 

Right Angle for Cleaning 179 

Interstitial Gingivitis . . 280 



Lactic Acid Treatment . . 372 

Law, for Dental Hygienist . 268 

For Dental Nurse . . 269 

Lecture by, 

Albray, Dr. R. A. . . 59 

Zarbaugh, Dr. L. L. . . 62 

Lecture of Michigan Dental 

Society 36 

Lecture on Mouth Hygiene 58 

Lecture to Boy Scouts . . 59 

Children 56 

Kindegarten Children . 57 

Mothers' Clubs ... 55 

Nurses and Physicians 56 

Lime Water as a Mouth 

Wash 170 

Literary Colleges, Oral Hy- 
giene in 10 

M 

Malocclusion 323 

Marion School, Experiment 102 

Massachusetts Dental Law . 268 

Mastication of Food ... 28 

Match Factory .... 5 

Mercury, Succinimide . . 387 

Metropolitan Life Dispensary 6 

Micro-organisms in Pyorrhea 293 

In Ordinary Mouth . . 66 

Morristown Clinic . . . 122 
Mouth Hygiene 

(See also Oral Hygiene) 

Bridge Work .... 448 

Care of Brush . . 78, 162 
Movements of Tooth 

Brush . . . 143, 46, 150 
Popular Education 7, 103, 109 
Silk Floss . . . 166, 178 
Temporary Teeth, care of 

24, 25, 40 

Mouth, the Neglected . . 31 

Rinsing 91 

Mouth Wash 203 

Mouth Wash, Lime Water . 170 

Mucin, in Saliva .... 248 



Index. 



461 



N 

Navy, Oral Hygiene in . 8 

Necrosis 313 

Nomenclature 281 

Notification Cards, in 

Prophylaxis 224 

Nurse, Dental . . . 251, 259 

Legal Status of . . . 267 



Odor in Pyorrhea .... 323 

Oklahoma School Work . 107 
Oral Hygiene in (see also 
Mouth Hygiene) 

Army 8 

Bridgeport .... 117 

Children 19 

Girard College ... 12 

Infant's Mouth ... 14 

Literary Colleges . . 10 

Navy 8 

Oklahoma 107 

Tuberculosis .... 145 
Oral Prepartion for Surgical 

work 455 

Oral Prophylaxis (see Prophy- 
laxis) 185 

Oral Sepsis, Dr. Hunter's 

paper 449 



Parasites in Pyorrhea . . 295 

Peridental Membrane . . 311 

Attachment of Fibers . 322 

Physicians and Mouth Care 448 

Physiological Salt Solution 398 

Pockets, Pus 319 

Polishing Powders . . 217, 218 

Porte Polishers .... 215 

Post-Operative Dressing . 405 

Powder, Tooth .... 7G 

Powders, Polishing . . . 215 

Prognosis, in Pyorrhea . . 333 
Prophylactic Treatment of 

Fissures and Grooves . 220 

Sensitive Areas . . . 221 

Soft Spots .... 221 

Prophylaxis, Definition . . 185 
Application to Dental 

Caries .... 201, 241 
Application to Pit and 

Fissure Decays . . 221 

Frequency of Treatment 198 

Notification Cards . . 224 
Notification System 

232, 234, 235 



Object of ... . 


200 


Opposition to . . 18 


5, 211 


Preliminary Work in 


205 


Results of Treatment 


240 


Technique of . . . 


206 


The "Class" . . . 


204 


When to begin . 


197 


Why necessary 


194 


Prophylaxis, Instruments 




used in 


214 


Prophylaxis, Teaching in 




Dental Colleges 


271 


Ptyalin in Saliva . 


247 


Pulp of Tooth .... 


49, 50 


Removal of 


416 


Pumice, Powder . 


180 


Pus, order of, in Pyorrhea 


323 


Pus, pockets, formation of 


319 


Pyorrhea Alveolaris . 


279 


A. A. Pyorrhea Treat- 




ment 


404 


Acid Treatment . 


373 


Amputation of Roots in 419 


Anesthesia in . . . 


393 


Artificial Teeth in . 


340 


Autogenous Vaccines 


429 


Auto-Intoxication in 


409 


Bacteriology of . 


293 


Bifiuoride of Ammonia 37- 


Bifurcation Treatment 




368, 415 


Blood Pressure in . 


340 


Bridgework in 


422 


Business side of . 


436 


Carious Bone in . 


313 


Congestion of Gums 


306 


Constipation in 


. 326 


Death from 


339 


Definition .... 


. 285 


Deposits in 


. 301 


Diagnosis of . 


325 


Drugs used in Treatme 


nt370 


Duration of . 


324 


Emetine, Treatment in 


L 


296, 29 


9, 432 


Endameba Buccalis . 


. 296 


Ethyl Borate in . 


379 


Implantation . 


. 413 


Infection, Specific, as 1 


i 


Cause .... 29 


2, 294 


Instrumentation . 


. 353 


Micro-organisms . 


293 


Movements of Teeth in 


. 323 


Necrosis in 


313 


Nomenclature . 


. 281 


Pain in Scaling . 


. 393 


Pathology of . 


. 30G 


Peridental Membrane ir 


L 311 



462 



Index 



Pyorrhea Alveolaris — Cont'd. 

Pocket Treatment 

Prognosis in ... 

Radiograph in 

Recession of Gums in . 

Relation of Parasites . 

Resection of Gum 

Salivary Calculus in 

Separation of Teeth in . 

Serumal Calculus 

Silver Nitrate in 

Skill Necessary for Ope- 
rating . . . 342, 

Sordes . . . . . 

Splints for .... 

Sterilization of Insru- 
memts for Pyorrhea 
work 

Succinimide of Mercury 
in 

Surgery of Root Surface 

Synonyms 

Syphilis in .... 

Systemic Condition as a 
Cause of . . . 381, 

Tartar in 

Teaching in Dental Col- 
leges 

Treatment Should be In- 
stituted Early . . . 

The Alveolar Process in 

Training of Patients to 



391 
333 
328 
30G 
295 
309 
301 
322 
303 
410 

371 

302 
424 



353 

387 
354 
279 
327 

409 
301 

271 



312 



Prevent 


408 


Treatment of 359, 360, 362 


365 


Tumefaction of Gums in 


308 


Wasserman Test in . 


326 


R 




Radiograph in Pyorrhea 


328 


Record of Cases in Pyorrhea 


229 


Rochester School Forms 


137 


Root Absorption .... 


317 


Root Amputation .... 


417 


Recession of Gums . 


306 


Rinsing Mouth .... 


91 


Root Bifurcation Treat- 




ment 368, 


415 


s 




Saliva 244, 


248 


Ptyalin in .... 


247 


Sulpho-Cyanide of Pot- 




tasium in ... 


247 


Salivary Calculus .... 


304 


Salivary Depressants 


202 


School Forms in 




Cincinnati 


135 


Cleveland 


133 



Detroit 139 

Rochester 137 

School Inspection .... 101 

How to Start .... 105 

Reasons for ... . 112 

In Ann Arbor . . . 101 

Cambridge .... 101 

Chicago 101 

Russia 101 

Sensitive Area Treatment . 221 
Separation of Teeth in 

Pyorrhea 322 

Sermual Calculus .... 303 

Silk, Dental Floss . . 166, 178 

Silver Nitrate Treatment . 410 
Sixth Year Molars . 24, 25, 40 

Soft Spots, Treatment of . 221 

Sordes 302 

Splints 424 

St. Augustine Clinic . . . 125 

Sterilization of Instruments 353 

Succinimide of Mercury . 387 

Sulpho-Cyanide of Potassium 247 

Surgery of the Root Surface 354 

Syphilis in Pyorrhea . . 327 



Tartar, Feeling of . . . 396 

Tartar in Pyorrhea . . . 301 

Formation of ... 304 

Teaching in Dental Colleges 272 

Teeth and Their Care . 36, 162 

Teeth, Cleaning of . . . 173 

Separation of in 

Pyorrhea . ... 322 

Tooth Brushes ... 47, 150 

Tooth Brush Drill ... 143 

Tooth Decay 48 

Tooth Enamel 241 

Tooth Pick, Proper use of . 165 

Tooth Root Absorption . . 317 

Tooth Structure .... 4S 
Treatment of Fissures and 

Grooves 218 

Trichloracetic Acid . . . 373 

^Tuberculosis 145 

u 

Uncleanliness as a Cause of 

Pyorrhea 292 



Vincent's Bacteria 
W 



326 



Wassermann Test in 

Pyorrhea 326 



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